Chronic vaginal candidiasis - Management in the postmenopausal patient

Vulvovaginal candidiasis (VVC) is a cause of significant morbidity in many women of a childbearing age worldwide. There is a paucity of literature on the prevalence of this condition in postmenopausal women, although it is believed to be uncommon because of the estrogen dependence of VVC. Postmenopausal women who have underlying risk factors for WC (e.g. hormone replacement therapy, uncontrolled diabetes mellitus, immunosuppression caused by medication or disease) may be at risk of chronic or recurrent VVC. However, as in younger women, it is likely that, even after exhaustive investigations, no cause will be found in a significant number of patients. The investigation and treatment of VVC in older women should be the same as that undertaken in younger women. Both topical and oral preparations are available, but oral regimens are perhaps more acceptable because of the ease of administration and avoidance of potentially messy creams and suppositories. Ketoconazole at a dosage of 400mg daily for 14 days can be used to achieve clinical remission of symptoms and negative fungal cultures. Induction treatment should be followed by maintenance therapy for 6 months with ketoconazole 100mg daily, itraconazole 50 to 100mg daily or fluconazole 100mg weekly or 150mg monthly. Short courses of topical therapy, e.g. 500mg clotrimazole pessaries as a single weekly dose for 6 months or 100mg miconazole pessaries twice weekly for 3 months, followed by once weekly for 3 months may also be used. Vulvovaginal candidiasis (VVC) affects millions of women worldwide. It is estimated that 75% of women will experience at least one episode of VVC in their life.([1,2]) A much smaller (probably less than 5%), but still significant, number of women will suffer from repeated, often intractable, attacks.([2]) Much of the published work on VVC has been done in premenopausal women, and although the condition is said to be uncommon in women after menopause,([3,4]) there is a distinct paucity of literature to support this claim. Symptomatic infection in postmenopausal women is usually associated with uncontrolled diabetes mellitus, hormone replacement or antibiotic therapy, severe underlying disease or immunosuppressive agents and, recently, the anti-estrogen drug tamoxifen.[3] The prevalence of chronic or recurrent (4 or more episodes of mycologically proven, symptomatic infection in a 12-month period) VVC (RVVC) in postmenopausal women is unknown. In most premenopausal women with RVVC, no predisposing factor is found, and although little work has been done in older women, one assumes that this is also likely to be the case in this group.