Could this be trich?

[llle]

Dr. H - Thanks again for the great service you provide here.



For the last 8 months, I have had what has appeared to be a yeast infection.  It has not responded to Monistat well and has required multiple doses of Diflucan to eliminate the symptoms, only to return 4-8 weeks later.  



HSV/Chlamydia/Gonorrhea/HIV/HPV all negative. My Pap and visual inspection was completely normal and a wet-mount was done (not during symptomic time) which showed "nothing abnormal at all" (I'm assuming this means no Clue cells, Wht Cells, trich, etc.)  



I have no discharge when asymptomatic and mostly thick white discharge when symptoms present.  Symptoms include severe itching/burning around labia and opening of vagina but  not in vagina at all.  Also have swelling, redness and throbbing during symptoms.  After treatment with Diflucan, symptoms totally go away until 4-8 weeks later (prior to..had about 1-2 yeast infections per year).  In between episodes, no pain/irriation, no pain with sex, no bleeding, no discharge/foul smell.  The wet mount also did not show yeast,  but it was done when I was asymptomatic.  



Here are my specific questions...



1.  could this be trich that is not showing up on a wet-mount? How accurate/reliable is a wet mount (performed by the NP at Planned Parenthood)?  



3.  considering the continued problem, should a culture be done to make sure it's not trich or is that not necessary?  Or maybe a culture is needed to determine what type of yeast?



4.  would trich respond to diflucan, relieiving symptoms only to return?(do trich symptoms fluctuate  or once a person has trich, the symptoms are always present, only varying in intensity?)



5.  If this is yeast and it is obviously a chronic problem, should a maintanence schedule of Diflucan be appropriate and if so, what would that be?  6 weeks?  longer?



I am very frustrated by this and would love any insight you can give me.  Thanks for your help.

[H. Hunter Handsfield, M.D.]

As you suggest, the lack of prompt response to miconazole and fluconazole (Monistat and Diflucan) suggests that yeast may not be the primary problem.  However, some yeasts are not susceptible to those drugs.  Most yeast infections are due to Candida albicans, which is susceptible; but some infections are caused by C. glabrata, which often is resistant to the azole drugs.  So if not yet done, you need a culture for yeast--not just a micrscopic test--to see if you have C. albicans, C. glabrata, or neither one.  If your own provider is not on top of those issues, you should seek out an ObG with infectious disease expertise.  Such persons often can be found at major medical centers, especially those associated with medical schools.



Also, you might have neither yeast nor trichomonas.  Perhaps idiopathic (cause unknown) vulvar pruritus or vulvodynia.  Diagnosis and management of this problem also should rely on a specialist, who also will be in the best position to suggest treatment.



1) Your symptoms do not sound like trichomonas, which typically causes smelly yellow or brownish discharge--not vulvar irritation with scant, thick discharge.  This isn't hard and fast, however.  Also, wet mount picks up only 50-60% of trichomonas cases.  You might ask your NP about doing a culture, not just a wet mount.  Alternatively, since trich almost always responds to simple, single-dose treatment with metronidazole (Flagyl) or tinidazole (Tindamax), you might ask your provider whether it's worth seeing whether treatment resolves your symptoms.  But don't get your hopes up; I doubt you have it.



3) As already stated, culture for yeast is definitely a good idea; and maybe for trich.



4) Trich does not respond to fluconazole or other yeast treatments.



5) I can't advise on specific treatment options at this point.  You should leave that to a knowledgeable provider, after doing the additional diagnostic tests.



I hope this helps.  Best wishes--  HHH, MD

[llle]

Thanks for your prompt reply and comments.  This will probably not change your advice, but my Pap and visual exam were done by my OBGYN who I think is very knowledgable.  He has been practicing for >25 years plus teaches residents.  The wet mount was done by the NP at Planned Parenthood, who I am assuming has seen her fair share of trich, yeast, etc. (both stated everything looked normal)

I have done some searching on the Internet and have read about the other yeast, c.galbrata?  What I read is that this usually only occurs in immunocompromised women, occuring rarely in healthy women. Is this true?  If so, the odds are that it is probably not that, correct?  I trust your knowledge far more than anything I could look up on the internet.

I also was not that clear on the Diflucan response..the symptoms seem to dissapear within a few days of taking the first dose, however, my OBGYN always seems to give me 3 doses to take.. one, then the 2nd 3 days later, then the 3rd 7 days after that.  My issue is that it doesn't stay away, coming back within a few weeks or months.

Just to clarify,  if it were trich, the Diflucan would not cause any relief of symptoms, correct? (because I am getting relief for awhile)

Regardless, I will pursue a culture, and if negative, pursue the ideopathic route.

Anyway, I know you don't have to respond again, but I do appreciate your help in sorting through this and again, I hope you know how invaluable this service is to a lot of people.  Thanks.

[llle]

Oh, one more thing I forgot to add.  I'm curious more just to answer my question than because of my symptoms, but when searching on the internet, I could not get an answer to this question...

If a person develops symptoms due to trich, do the symptoms continue to stay around without relief until properly treated or do they come and go, leaving periods without symptoms, only to return?  I found numerous sites stating the symptoms vary in intensity but that was about it.

I know....curiousity killed the cat....:)

[H. Hunter Handsfield, M.D.]

Sorry, I misunderstood your original question, thinking fluconazole wasn't working at all.  You fall into the category of "complicated" yeast vulvovaginitis, as defined in the CDC's latest (2006) STD treatment guidelines, which includes frequently recurrent infections.  The guidelines have specific recommendations for management.  As I recall, one approach is prolonged (e.g., 10 days) initial treatment, followed by weekly single-dose oral fluconazole for a prolonged period to prevent relapse.  If your provider isn't up to speed on the CDC recommendations, s/he can look them up online at www.cdc.gov/std.



C. glabrata indeed is more common in immunodeficient persons, but has been increasing in frequency in immunologically normal persons in the past several years.



I don't have any additional information about patterns of itching in women with yeast infections.  This really isn't a problem we deal with much in STD clinics, since yeast isn't an STD, and we refer women with unusual cases to our ObG colleagues.



Good luck--  HHH, MD

[llle]

Thanks for your help and advice.  I greatly appreciate it.  This will help me move forward through the proper channels for treatment.  Again, thanks.

[llle]

Was re-reading your second post regarding the Diflucan regime.  One last question for clarification from your comments.  



Based on the fact that the wet mount showed nothing and my symptoms are relieved with Diflucan for a period of time, can I safely assume that this is not trich and that I don't need to pursue that further with a culture for trich?  Can I just move forward with the recurrent yeast treatment?  



Thanks...last post from me.

[H. Hunter Handsfield, M.D.]

That's up to your ObG.  But if s/he is confident that the problem is yeast infection, I would treat you accordingly and see no need for trich culture.

[Jay-Bird]

Does chlamydia cause a smelly discharge

[llle]

Dr. H - I hope you will read this even though my original post was a month ago.  This is a follow-up to the original post...I have had 2 wet-mounts now, showing no signs of "anything".  Slightly red labia on examination but vagina looks normal but still having labial burning/itching (mostly around clitoris/hood), no discharge.  pH of vagina is around 4.5.  Neither provider thinks a culture for trich/yeast is necessary, even with the symptoms I'm having.  Here are my questions that I can't get answers for...
1.  Is trich transmitted ONLY through penetration?  Some say there must be actual unprotected penetration intercourse to acquire trich, no just sexual activity and others say the opposite?
2.  Is a pH of 4.5 normal?  it seems borderline to me but what is the usual pH of trich?  I've read >4.5 but have also read it is usually around 6-7.  Does a 4.5 pH pretty much rule out trich?  Does the pH of trich vary within one person or does it stay the same?
3.  Why not do a culture?  Does the ph level, plus 2 negative wet-mounts seem reasonable to r/o trich?
I appreciate any answers.  I would like to get to the bottom of this(no pun intended)

[H. Hunter Handsfield, M.D.]

As I said above, there really is no reason to suspect trich.  You need to drop that possibility from your mind.  1) Trich is only acquired sexually, but it isn't known whether penetration is required or genital apposition with penetration might be sufficient.  2) pH 4.5 is perfectly normal; and yes, symptomatic trich infections always have higher pH than that.  3) A culture could be done, but I see no need.

This is your last question on this thread and my last reply.  Further follow-up/questions should be with your personal provider.