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 pos tmenopausal women, although it is believed to be uncommon because of the es trogen dependence of VVC. Postmenopausal women who have underlying risk fac tors for WC (e.g. hormone replacement therapy, uncontrolled diabetes mellit us, immunosuppression caused by medication or disease) may be at risk of ch ronic or recurrent VVC. However, as in younger women, it is likely that, ev en 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 a vailable, but oral regimens are perhaps more acceptable because of the ease of administration and avoidance of potentially messy creams and suppositor ies. Ketoconazole at a dosage of 400mg daily for 14 days can be used to ach ieve clinical remission of symptoms and negative fungal cultures. Induction treatment should be followed by maintenance therapy for 6 months with keto conazole 100mg daily, itraconazole 50 to 100mg daily or fluconazole 100mg w eekly or 150mg monthly. Short courses of topical therapy, e.g. 500mg clotrimazole pessaries as a si ngle weekly dose for 6 months or 100mg miconazole pessaries twice weekly fo r 3 months, followed by once weekly for 3 months may also be used. Vulvovaginal candidiasis (VVC) affects millions of women worldwide. It is e stimated that 75% of women will experience at least one episode of VVC in t heir life.([1,2]) A much smaller (probably less than 5%), but still signifi cant, 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 un controlled diabetes mellitus, hormone replacement or antibiotic therapy, se vere underlying disease or immunosuppressive agents and, recently, the anti -estrogen drug tamoxifen.[3] The prevalence of chronic or recurrent (4 or m ore episodes of mycologically proven, symptomatic infection in a 12-month p eriod) 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 t he case in this group.