Need some advice....

[girl522]

Dr. HHH,

Two years ago I took amoxicillin and ever since then I have had persistent yeast and BV infections.  I had never had any problems until then.  A few days after finishing the amox I got my first yeast infection.  Now it seems as if I alternate between that and BV every 2 months. I am 20 years old and a college student who doesn't work.  I have health insurance which sucks and everytime I go to my gyn it is $130 for the visit and $25 for the wet mount so as you can see this is getting pricey.  I was just wondering if there is anything you can suggest for preventative care.  I have heard that taking lactobacillus can help and something new out I think it is called rephresh ( or something like that).  I'm wondering if my pH is off.  As this is starting to really depress me and ruin my sex life.  I have been with the same person for 3 years and have never had any stds.  My gyn has tested me for chlamydia, gonnorhea, diabetes...all negative.  No hygeine problems here either.  Someone told me your diet has a lot to do with it which i don't really believe.  I am a college student so I don't have the best diet or the time to try to eat "real meals". My mom said something about throwing wet towels around and then using them again can cause infections.  She said they need to properly dry otherwise bacteria can grow on them to, is this true? Also I seem to have no sex drive for the past year, don't know if this is related? For yeast infections I take either difulcan or boric acid capsules and for BV flagyl. Any advice you could give would be truly appreciated.

[H. Hunter Handsfield, M.D.]

Having both recurrent yeast and BV is unusual, so one of my first thoughts is to wonder whether you really have both.  You might discuss it with your provider, unless you're already quite certain.  For the moment, though, I will assume you have both recurrent yeast infections and recurrent BV.  Both infections can be related in part to depletion of normal protective bacteria from the vagina (primarily certain strains of lactobacillus).  Whether the amoxicillin really was the initial problem is hard to say, but that antbiotic has the capability of destroying vaginal lactobacillus, so it is a possibility.  Your vaginal pH indeed probably is "off" some of the time, but that is circular reasoning:  it is lactobacillus that maintains normal acidity.  (That is, reduced acidity may be a manifestation of the underlying problem, not a contributing cause.  But there is a lot of scientific uncertainty here.



You are absolutely right that neither hygiene nor diet is the problem.  Such issues as tight clothing (jeans in summertime) and diet influencing vaginal infections are urban legends.  Ditto for re-using towels, direction of wiping after urination or defecation, etc.  Given what I said above, it is simple common sense that putting lactobacillus into the vagina should help, right?  Problem is, no commercial lactobacillus preparations contain the right kinds of lactobacilli.  The strains common in dairy products (L. casei, L. acidophilus) do not survive in the vagina and have no preventive or curative effect; eating yogurt (or douching with it) is useless, as are lactobacillus products you can purchase in health food stores.  Intensive research has been going on for a decade to convert the protective kinds of lactobacilli into products that will successfully colonize the vagina, but to date success has been spotty at best.  So maybe someday, but not yet.



So what do you do?  The yeast part is easiest:  most women with recurrent yeast can take fluconazole (Diflucan) once a week and completely prevent symptomatic infections.  If this hasn't been tried, you should discuss it with your ObG provider.  Such preventive treatment appears to be safe and usually remains effective months or even years on end.



Unfortunately, I can't be so optimistic about recurrent BV.  The syndrome is not an STD, but is associated with sexual activity, and some women say they stop having problems if they and their partners consistently use condoms.  Another issue, which may or may not apply to you:  you don't say the sex of your partner, but among lesbian women, BV clearly is sexually transmitted.  That is, when women share their vaginal secretions through hands or sex toys, if one has BV, the other always has BV.  But one of those partners might have a mild case and be asymptomatic, so it isn't obvious.  In such circumstances, treating both partners simultaneously might help, perhaps coupled with abstinence for a few weeks, or limiting practices (barriers etc) to avoid vaginal secretion exchange.



From a clinical perspective, I cannot link your vaginal infections with reduced sex drive--except for the possibility of stress or anxiety as a contributor.  But sexual functioning per se is outside my expertise.  Sorry.



This is a scientifically complex area, frustrating for patients and providers alike.  I hope this information helps.



Best wishes--   HHH, MD

[girl522]

My partner is my boyfriend.  One thing my gyn asked me was if he was circumcized, which he isn't since he is from germany and they don't do that there. She said to make sure he washes very well since bacteria and things can get in the foreskin which he does.  But he does not believe this is the problem since he says if this was the case everyone in germany would have these infections.  But we do live in the south where it is very hot and humid.  Sometimes when school is crazy we will abstain for 2 weeks or so and I still seem to get the infections. So I don't think that has anything to do with it.  I just hope I can that I can get rid of these infections for good.  Is this common for someone of my age?  I'm only with one person and don't engage in any other risky activities.  I took microbiology last semester and my professor was talking about how any inflammation of the vagina ( whether it is an STD or not) greatly increases your chances of reproductive cancers and can cause infertility.  I am little worried about this because I do want to have children one day.  Is this true?  I mean I'm only 20 and I've had at least 10 infections already.

[H. Hunter Handsfield, M.D.]

To my knowledge, partner circumcision status has never been linked to BV or any other vaginal infections in women.  (However, being uncircumcised increases a man's risk of acquiring HIV and certain other STDs, if exposed.)  Likewise, objective research has never implicated environmental temperature or humidity with risk of vaginal infections, notwithstanding common beliefs; that too is an old wives tale.



The general sense that vaginal inflammation or infection might increase the risk of cancer or other reproductive health threats is outmoded by a couple of decades.  It may be true, but the emphasis in recent research focuses on specific infections, not the general case you suggest.  To my knowledge no data have linked recurrent yeast to such outcomes; and BV actually does not cause inflammation.  To the extent there is risk, it is small; there is nothing in your story that makes me concerned about your future fertility.



Congratulations for keeping a very level head about all this, regardless of the frustrations--i.e., maintaining skepticism about all the old wives tales!



As far as specific suggestions, I already suggested you discuss weekly fluconazole with your provider.  If you are using any vaginal products of any kind (douches, deodorants, etc) totally stop any such stuff.  (Douching in particular is a common cause of BV--and women can get into a vicious cycle, believing that douching will control symptoms like odor and discharge, but it just perpetuates the problem.)  Finally, you can ask your ObG to refer you to an ObG colleague with particular expertise in infectious diseases; such specialists are available at most large medical centers, especially if affiliated with a medical school.



HHH, MD

[girl522]

I actually happen to volunteer at our medical school's hospital ( but in the children's part), so I will have to see who I can find there.  Thank you so much for the advice.  I really appreciate it, this is very frustrating but hopefully there will be an end soon.