Warner Huh (Host): Hello everyone, this is Dr. Warner Huh, the Chair of OB-GYN here at the University of Alabama at Birmingham. I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh. So today, we're going to talk about something that our listeners may not know that much about, and that topic is vaginitis, really what you need to know.

And with me today are two really amazing physicians. The first one is Dr. Christina Muzny, who is a Professor in the Division of Infectious Disease in the Department of Medicine here at UAB. She's also the Chair of our Institutional Review Board, which is a huge job, as well as Dr. Olivia Van Gerwen, who's an Assistant Professor also in the Division of Infectious Diseases in the Department of Medicine. They both jointly run the Vaginitis Clinic here at UAB, which you'll learn more about. We'll be talking about that later in the podcast, but we want to welcome you both to this monthly podcast.

Dr. Christina Muzny: Thank you so much. It's exciting to be here.

Dr. Olivia Van Gerwen: Thanks for having us.

Host: So, let's just dive right into it. I think probably our listeners are kind of curious about what exactly is vaginitis. So, Dr. Muzny, I thought maybe you just talk about what is vaginitis and maybe if you can briefly just talk about the symptoms and the causes of vaginitis.

Dr. Christina Muzny: Yeah, I think a high level overview of it is that vaginitis is typically an inflammation of the vagina where we get a change in the balance of the healthy and unhealthy vaginal bacteria that live there. Most commonly, symptoms are going to be vaginal odor, vaginal discharge, itching sometimes, and also pain, particularly during sexual activity.

Host: What typically causes it?

Dr. Christina Muzny: So, some of the most common causes are bacterial vaginosis. That's the most common cause of discharge. Also, there's a parasitic sexually transmitted infection, trichomoniasis that can cause vaginitis and also yeast infection. So, a lot of women, I'm sure, have heard about yeast infections and maybe have experienced them during their life.

Host: And can you just give us an idea or share with the listeners like how common is this? I know the answer to this question, but I thought you might want to share how prevalent it is in the general population.

Dr. Christina Muzny: Yeah. So bacterial vaginosis, extremely common. The most common out of all of them. It's about 30% global prevalence of this infection. So, one out of three women typically during their lifetime would get an episode of this. Trichomoniasis varies based on the population. Right now, the national average in women is about 2%. Here in Birmingham at our patient populations, we see between 10-20%. And the yeast infections, it can also vary between populations about 20-40% prevalence, depending on your risk factors.

Host: I thought I knew the data, but clearly I don't, which is that numbers are a lot higher than I thought that they were really. So, you're really telling me for vaginitis, like in our population in Birmingham, it's like one in five, basically, as you're saying.

Dr. Christina Muzny: Absolutely.

Host: That's highly prevalent.

Dr. Christina Muzny: Highly prevalent.

Host: Right. So Dr. Van Gerwen, let me just ask you, how is this diagnosis made, given that we have bacterial causes, including a sexually transmitted infection, fungal causes, or yeast causes how do you like work up a patient that comes to see you with this, basically, in your office?

Dr. Olivia Van Gerwen: As with a lot of things in medicine the history is really, really important. So when you have a patient who is talking to you about these symptoms that Christina just described, you know, getting a really good sexual history is extremely important. BV is up in the air whether or not it's sexually transmitted versus just associated with sex. But certain sexual practices can be a risk factor for things like bacterial vaginosis. And trichomoniasis is known to be sexually transmitted. So, getting a good history on that is very important.

And another piece of history that's really important is understanding who the host is, who the patient is. So if they have some kind of immunocompromising condition like HIV, if they have some kind of hormonal change going on in their lives, such as pregnancy, menopause, anything like that, those can be risk factors for things like bacterial vaginosis and candidiasis. And then, you can also see things that are important like diabetes in terms of immunocompromised status. So, looking at risk factors in your patient is really important.

And then also, beyond the history, there are lots of different diagnostics that you can do as a provider. So once you get the history from the patient, if you take a specimen from vaginal fluid, looking at it under the microscope in what we call a wet mount preparation, you can see yeast forms under there. You can see different organisms that make indicate that they have bacterial vaginosis and you can see presence of things like trichomoniasis. One thing that's really exciting about doing work in vaginitis is being able to diagnose people at the bedside, which is what we do at our clinic.

But there are, as with a lot of things in infectious diseases, new diagnostics coming out all the time. So, we do have molecular diagnostics, which are kind of like what we think of when we think of, for example, a COVID test, you know, checking for different pieces of the different organisms to rapidly detect them in a molecular setting as well. And then, we also do cultures for things like yeast.

So, that was a long-winded answer, but I think history is the number one most important thing and understanding who the patients are with the wide array of options that you have for diagnosis, etiologies of the vaginitis syndromes, but also the diagnostics that we have are really important.

Host: Do we use those "diagnostics" here at UAB? Is that something you use regularly?

Dr. Olivia Van Gerwen: In our clinic, and I know at a lot of the gynecology clinics, we do a lot of bedside microscopy diagnosis with the wet preps. And we do fungal cultures for diagnosing vulvovaginal candidiasis.

At this time for things like bacterial vaginosis and candidiasis, we don't have any molecular tests that we do, but Christina and I are working with our microbiology lab and the people who run that program to try and get those things in the hands of our clinicians so that we have more testing options.

Host: Okay. That's great. So, let's just roll up our sleeves and get into sort of some major topics, which are treatment options for vaginitis. I thought maybe one of you can kind of help me answer the question. So, what exactly is available to women in this day and age? And, you know, how do you approach treatment options in this space?

Dr. Christina Muzny: Yeah. I think this is a very important part of this. There are some treatment options available over-the-counter that patients can just access versus them coming to clinic and getting a firm diagnosis and us diagnosing exactly what they have. And I just wanted to say, we don't just see one vaginal infection by itself many times. We see mixed vaginal infections as we call it. So, women may have two or they may have all three occasionally. And so, the treatment gets a lot more nuanced the more complicated you get. But treatment does differ based on which infection.

So for bacterial vaginosis, we have oral and intravaginal treatments, all of those are prescription. So like oral metronidazole, oral clindamycin, we have intravaginal metronidazole available. For trichomoniasis, it's all oral medications only. There's no good data showing that vaginal medications work for trichomoniasis. And then, for yeast we have fluconazole as our most commonly prescribed oral medication. And then, we have a lot of over-the-counter yeast medications vaginally that we can give. It is important to note though, recently, the guidelines have changed that fluconazole should not be used orally in pregnant women.

Host: In pregnant women, okay. All right. I don't mean to put you on the spot, there's a lot to kind of unpack there. How effective are those over-the-counter treatments for yeast infections? I get asked this question a lot from my patients, and I think they've made the connection, many of them, that there's this pill, one or two tablets, you take and you're done. But how effective are the over-the-counter preparations that are available?

Dr. Christina Muzny: Yeah, I think it really depends per patient on if this is a very simple sporadic yeast infection that maybe they're having after they've taken a course of oral antibiotics versus if somebody's having a chronic recurrent vaginal yeast infection. So, the over-the-counter preparations work much better for sporadic vulvovaginal candidiasis, much less often for recurrent or persistent infection.

Dr. Olivia Van Gerwen: The most recent CDC guidelines for STIs have a section about candidiasis, and they do recommend these over-the-counter topical antifungals as a first line treatment. But like Christina said, the best situation to use those in are the more simple cases. We don't do a lot of that at our clinic where we see a little more complex patients that need something beyond the topical. But you know, run-of-the-mill cases, I'd agree it works really well for a lot of people.

Host: Okay. And in the same vein for things like bacterial vaginosis, do you have an opinion about whether vaginal versus oral is better or thoughts on that?

Dr. Christina Muzny: Yeah. So in the recommended therapies right now, two of them are oral and one is vaginal. And they all have similar efficacy. So, I think it just depends on the patient preference if they want to take a pill or if they want to do vaginally. And it just depends on if patient has had previous experience using this or cost may factor into it.

Dr. Olivia Van Gerwen: Some patients have trouble tolerating some of the oral medicines. For example, metronidazole gives people some GI upset. They can have nausea. So for example, women who have trouble with pills or nausea may prefer the intravaginal options. So, it's a patient preference, like you said.

Host: So as a big kind of prevention guy, my next question I think is kind of apropos, which is you know, I think we all have seen patients who are diagnosed with vaginitis and they're like, "How do I prevent this from ever coming back?" Right? So, how do you approach that? How do you approach, A, women who have recurrent vaginitis? Do you just treat them the same way or do you do something different? I know that's a somewhat of a complex question. Then two, are there known effective strategies that would prevent women from developing recurrent vaginitis or even primary vaginitis for that matter? I don't know which one of you wants to take that question on.

Dr. Olivia Van Gerwen: I can start. So, with BV, which, again, is the most common thing that we see, there are a couple things that people can do on a behavioral side of things. There are data that condoms are effective at preventing recurrence in patients who may have a regular sexual partner that continues to give them a disturbance in their vaginal microbiota. So, I do counsel patients that using condoms may help prevent this from happening again. And in addition to that, general kind of hygiene counseling can be really helpful, douching, doing things intravaginally that are not prescribed by a doctor and are not related to sex, you know, sometimes can disturb the vaginal microbiota, the flora that live in there naturally and can disturb the balance into something that's more dysbiotic and more like BV. So, I talk to patients about not using things like douches or any kind of products that they've seen on social media that have been promoted for vaginal health that isn't something they discussed with their doctor.

And then beyond that, after we treat an acute episode of BV for these folks who have recurrent infections and constant issues with them, there are data for maintenance antibiotic regimens that can prevent things from happening in the future. So, an example of that would be a patient comes in and has BV in the office. So, we give her, you know, seven days of metronidazole. And then after that, she will get a prescription for intravaginal metronidazole to use twice weekly for about four to six months. And the data for that is pretty good. After they complete that maintenance regimen, we can watch and hopefully decrease the frequency of their recurrences and maybe even prevent them from ever happening again.

So, that is BV. It's a similar concept for yeast as well. We do the acute treatment and we try to mitigate risk factors. So, remove antibiotics. If there's any way we can affect their immune status, we usually can't, you know, that is obviously something that would help. And then, the maintenance therapy for that is fluconazole once a week for six months as well. So, a maintenance antibiotic regimen kind of suppresses those bacteria and those fungi from coming back and giving patients symptoms.

Host: And just kind of following up on a comment that Dr. Muzny made, So, what percentage of women who have primary vaginitis will go on to develop recurrent vaginitis, do you think?

Dr. Olivia Van Gerwen: So with BV, I don't know the exact numbers.

Dr. Christina Muzny: Yeah, recurrence is 60-80% at 28 months in a landmark study.

Dr. Olivia Van Gerwen: It's very common.

Dr. Christina Muzny: It's very common.

Dr. Olivia Van Gerwen: And with yeast, it's about 15% of people will have recurrence. It's not quite as common, but the ones who do have it, they struggle a lot with getting it under control, because we have pretty limited treatment options for yeast.

Host: Yeah. I knew it was high and that's really probably the reason I'm asking the question, is to highlight to our listeners and the audience that it's more likely going to be a recurrent problem than just a primary one-and-done kind of issue basically.

Dr. Olivia Van Gerwen: And I think one thing that leads to that is a lot of times people will have symptoms and they may not come to be evaluated by a provider. They may kind of self-treat thinking this is a yeast infection, but it's never confirmed that it's yeast. It may actually be BV. So, they don't get their diagnostics done to determine what the cause of their vaginitis is, and they may not ever get appropriately treated. So, the symptoms just keep returning. So, there's a limitation there with people kind of self-treating and self-diagnosing as well.

Host: I want to go back to something that you said, which I think is important that we underscore, which is the lack of value of douching. I can't tell you how many patients I have who have vaginitis symptoms, and they believe that flushing this out by douching is actually really good. Can you explain just briefly like why that is and reinforce why that is a bad idea?

Dr. Christina Muzny: Yeah. So, douching can change your composition of your vaginal bacteria. And there's something called lactobacilli that are present in the vaginal canal. And many of those are what we call happy bacteria, and they produce lactic acid and hydrogen peroxide that helps keep the environment with a low pH and happy. And douching can change that composition of those bacteria and actually flush some of them out. And with that gone and that lactic acid production going away, it leads to these other bad bacteria overgrowing, which can lead to symptoms of BV.

Host: Yeah. And I think that goes to the point that you made early on in the podcast, which is vaginitis is an imbalance of the flora or of the bacteria that preexists within the vaginal canal. And vaginitis is essentially a disrupted or an imbalance of that basically.

So, another question about prevention is particularly for patients who have yeast infections, I get a lot of questions about, can you change your diet? And can your diet be modified to improve the healthy, normal, happy flora? Using your word, happy, which is actually perfect, but your thoughts about the effectiveness of that?

Dr. Olivia Van Gerwen: I think it depends on the patient. You know, if folks have diabetes or they have issues with blood sugar, I think the people who I see who their blood sugar kind of dictates when they're going to get another yeast infection, that's certainly true. But outside of that, I'm not aware of any data to support other types of diets that would prevent recurrences of yeast infections that are outside of that realm. Patients do a lot of research when they come to see us in clinic, because this is something that really disrupts their life a lot. And so, patients, they want anything that's going to help them. And so, a lot of them are really hungry for things like a diet that will help fix this. And supplements that will help fix this. And unfortunately, we're at a state in the natural history of this type of medicine where I don't think there's been a lot of attention paid to how to best treat these issues. And so, we don't have as many options as we do for some other types of issues that women face. And so, we do a lot of counseling about that.

Host: Yeah, I think that's a great point. I mean, considering that whether it's 20-33% of the patient population is afflicted with this, there's not a lot of funding, support, or research that goes in this area for such a highly prevalent problem.

So last similar question, and I just don't want to confuse the listeners, is you talked about treating vaginitis with antibiotics, yet at the same time, I think our patient population knows that antibiotics itself can trigger vaginitis. So, it seems kind of like threading the needle here, kind of darned if you do, and you're darned if you don't. Any thoughts about precautions that you provide patients who go on antibiotic therapy? Let's say they have a UTI or they have an upper respiratory tract infection. We all know that those women come in with a yeast infection. I just don't know if there's any advice that you could give to our listeners.

Dr. Christina Muzny: Yeah, I think to a lot of women they know their bodies and they know in the past if they've gotten a yeast infection before after they've taken a course of oral antibiotics for like a bronchitis or sinus infection. So, a lot of those people will just go ahead and preemptively prescribe one or two doses of fluconazole if they can feel those yeast type symptoms coming or tell them to call our clinic. But the one we worry about the most with people taking antibiotics obviously is the yeast infection, not so much BV or trichomonas. So, we just kind of preemptively help some patients in that way.

Dr. Olivia Van Gerwen: And if I have a patient who's coming to me for one of the bacterial causes or parasitic causes of vaginitis, and they say, "When I take antibiotics, I get a yeast infection," I try to suss out what the symptoms are that they associated with the yeast infection and do some educating about this may be a yeast infection, but this may be something else.

The typical symptoms for yeast are the chunky white discharge, very itchy, very irritated, and the skin gets kind of raw, which is a little bit different than the other vaginitis syndrome. So, distinguishing yeast From BV, at least somewhat when you're taking the history, can help you counsel patients and maybe avoid or know that you should give an antifungal preemptively.

Host: Great. This is awesome. Before I kind of present one of my last questions to you all, congratulations to you both for creating this Vaginitis Clinic. Long overdue. Many things make UAB unique, but this particularly makes this unique for women's health. Can you just comment and talk about what the purpose of the Vaginitis Clinic is? Obviously, millions of women are evaluated for vaginitis by their OB-GYNs, but what compelled you to start this clinic? And maybe comment on how one accesses the clinic.

Dr. Christina Muzny: Yeah. So, a lot to unpack in that question and thanks for asking it. So, we started the UAB ID Vaginitis Clinic in June of 2021, so almost three years ago. We did start it during COVID. And we started it because Dr. Van Gerwen and I were just getting emails and calls from all over the UAB campus and all around Alabama, mainly for patients at the time that were suffering from these chronic persistent vaginal infections and they did not know where to go or where to get treatment. And we really thought we had a niche training experience here at UAB and we really wanted to have an opportunity for these patients to come see us and get a little bit of a different perspective from an infectious disease provider's viewpoint.

Dr. Olivia Van Gerwen: Yeah. We both do clinical work in this space, obviously, but we both are very interested in the research into why BV exists and what causes it and how we treat it. And so, we see a lot of patients in the research setting who, as we mentioned, are just eager for solutions. And so, we thought, with our infectious diseases expertise, we could offer something to them in terms of treating these really difficult cases. So, we see patients who have infectious vaginitis syndromes such as BV, trichomoniasis, and yeast. And typically, the patients are referred to us from an OB-GYN or a primary care doctor when the run-of-the-mill stuff isn't working. So, we will do complex management for patients who, for example, may have resistant infections. So, we see a lot yeast infections that are resistant to our typical agents. We see a lot of people who have allergies to the medicines we normally use, or who just keep having symptoms no matter what their kind of first line doctor tries.

So, we're here for the really complicated cases and it's just a really special place. It's very fulfilling when you do fix something for someone that they feel has been a problem they've had not listened to for years and years and years. So, it's been a very valuable experience for me as a provider. It makes me happy to go home on Friday afternoon after that clinic most of the time.

Host: Yeah. I agree. I mean, my hats off to both of you and just for the listeners. This podcast is dedicated to women's health, irrespective of the provider and where the provider is from. And I have done podcasts with members of faculty outside of the Department of OB-GYN, and it's a great example of how two departments, Department of Medicine and Department of OB-GYN work together. So, it's a huge resource. Can a patient self refer themselves to this clinic or does the referral have to come from an OB-GYN or another physician or a PCP?

Dr. Olivia Van Gerwen: We pretty much take referrals from other physicians and PCPs for all patients. The cases are all reviewed by us to see if they're right for our clinic. There's a lot of people with vaginal symptoms that are not necessarily vaginitis and some of those patients may be better served by seeing an OB-GYN or seeing a dermatologist or another type of provider. So, we try to make sure that when we see patients, we're able to provide help to them. We're not wasting their time in an appointment where we can't provide some, insights. And so, we typically take referrals and then, review those referrals to see if they're appropriate for our scope.

Host: Okay. I know our listeners will ask us questions. I'll ask it for them. Can this be done through a telemedicine or telephonic kind of console? Or does this something have to be done in person?

Dr. Olivia Van Gerwen: The initial evaluation is really important to be in person. We need to do an exam of the patient. Like we said, we do a lot of bedside point-of-care microscopy evaluation to see what the cause of this vaginitis syndrome is. And that is really important to kind of disentangle in-person with the patient in front of you being examined and looking under the microscope and seeing what's going on with their particular symptoms.

But I have done several followups with patients via telehealth, and I do a lot of kind of corresponding with patients through the portal and over telehealth to make sure that we're keeping an eye on what's going on with them after we see them in clinic. So, initially in person, but afterward we do have some patients we see remotely.

Dr. Christina Muzny: Yeah. And the other good thing is that, if patients have interval concerns between their visits, we get them to come in and do a self-collected vaginal swab on their own time Monday through Friday while the clinic is open. And sometimes we make decisions based on that. So, there is that option in conjunction with, you know, a telemedicine visit for them. So, we're pretty versatile. But as Dr. Van Gerwen said, we do like to see the people in person for the first visit.

Host: Yeah. I'm just setting expectations for our patients, et cetera. I think that's important. Any other closing thoughts, guys? This is awesome. I I've actually learned a lot today.

Dr. Christina Muzny: Yeah. I think one thing I wanted to mention that our clinic also does, which is kind of unique is trichomonas culture. So, we have an opportunity to grow the trichomonas in our laboratory on campus and do drug susceptibility testing for different drugs. And this is kind of a unique niche that we've gotten into out of our research. And the only other laboratory I think in the country doing this is the CDC. So, we're pretty excited to offer this at UAB to our patient population and be able to go beyond just giving drugs for trichomonas that we don't know if they're resistant to or not. So, we're kind of excited about that too.

Dr. Olivia Van Gerwen: It makes a really big difference for some of these patients who just can't get rid of their infection. And then, we find out, well, the reason is because all of the recommended treatments are in the same drug class and you're isolate is resistant to that. And so, we can get really thoughtful about what might be the best next step for that patient and move away from the old paradigm that they were in. So, it's a really a great service that we have for them.

Host: It seems that that would actually be a regional or national resource for patients as well.

Dr. Christina Muzny: Yeah, it kind of has become. People have started sending us trichomonas isolates from around the country.

Host: Good for you. That's really cool. That's actually fascinating. Well, again, thank you to both of you. I really wanted this topic as a podcast because there's so much there. And we just have so many patients that have vaginitis. I thought this would be a really kind of a worthwhile primer to getting them to understand what it is, how we treat it, recurrent symptoms, et cetera.

So again, I want to thank you both for the update. And as always, please rate this podcast and we welcome any comments, particularly on topics that you're interested in. And for more information on women's healthcare services, including the Vaginitis Clinic and other clinical services that UAB provides, please check out uabmedicine.org. But until next time, thank you, and I hope you all have a great day, and I hope you're enjoying the weather. Peace out. Bye-bye.