alternative medicines in women with chronic vaginitis april 2011

Alternative Therapies in Women WithChronic VaginitisPaul Nyirjesy, MD, Jennifer Robinson, MD, MPH, Leny Mathew, MS, Ahinoam Lev-Sagie, MD,Ingrid Reyes, MD, and Jennifer F. Culhane, PhD

OBJECTIVES: To describe the use of complementaryalternative medicines in women with chronic vaginitisand to evaluate epidemiologic factors associated withthese treatments.

METHODS: In this prospective cohort study, patientswith chronic vaginitis completed a questionnaire aboutpast diagnoses and treatments. Information regardingdemographics, medical and social history, perceivedmental and emotional stress, and current symptoms wascollected. All patients underwent a standard physicalexamination and laboratory testing and were assigned aspecific diagnosis.

RESULTS: A total of 481 women were enrolled; 64.9%used complementary alternative medicines. The mostcommon treatments were yogurt and acidophilus pills. Inunivariate analysis, compared with nonusers, users ofcomplementary alternative medicines were younger(83.4% younger than 50 compared with 73.1%; P�.032),not African American (11.9% compared with 21.3%;P�.018), had increased measures of perceived stress(P�.008), and reported that their symptoms interferedwith both work (59.1% compared with 40.6%; P�.001)and social lives (57.9% compared with 40.2%; P�.001).Patients using complementary alternative medicines hadseen more doctors (median 2 compared with 1; P<.001)and were more likely to report a history of vulvovaginalcandidiasis (98.4% compared with 90.5%; P<.001) orbacterial vaginosis (34.3% compared with 22.8%;P�.007). In the multivariable analysis, interference with

social life, higher number of doctors seen, symptoms ofitching or burning, and previous diagnoses of yeastinfection remained associated with alternative medicineuse. A current diagnosis of vulvovaginal candidiasis wasnot associated with alternative medicine use.

CONCLUSION: Complementary alternative medicineuse is common in women with chronic vaginitis, partic-ularly in those who are young, have more disruptivesymptoms, and report greater stress.(Obstet Gynecol 2011;117:856–61)DOI: 10.1097/AOG.0b013e31820b07d5

LEVEL OF EVIDENCE: II

Complementary and alternative medicine (CAM)is a source of many common interventions used

in the treatment of a variety of medical conditions inthe United States. The National Institutes of Healthhas found that 38% of the adult population in theUnited States uses some form of CAM.1 CAM thera-pies also are often used in the treatment of chronicconditions as opposed to acute or life-threateningillness, and a significant number of patients do notdisclose their use of CAM to their conventionalphysicians.2 A common situation in which gynecolo-gists may encounter patients using alternative thera-pies is in the treatment of chronic vaginitis. Vaginitisremains one of the most common reasons for awoman to visit her gynecologist, but patients alsohave the option of self-treatment with widely avail-able over the counter (OTC) antimycotic or alterna-tive therapies.3 Although a woman’s ability to accu-rately self-diagnose vulvovaginal candidiasis has beencalled into question,4 the use of these products hassky-rocketed, with an estimated $275 million spentannually just on OTC antifungal agents.5 Alternativetherapies that are commonly used for vaginitis in-clude probiotics, boric acid, douching, tea tree oil,and garlic.6

Although the extent of use of alternative medi-cines in women with chronic vaginitis has been

From the Departments of Obstetrics and Gynecology, Drexel University Collegeof Medicine, Philadelphia, Pennsylvania; and Mt. Scopus, Hadassah-HebrewUniversity Medical Center, Jerusalem, Israel.

Supported by a grant from the Pennsylvania Health Formula Fund (ME01-317).

Corresponding author: Paul Nyirjesy, MD, 245 North 15th Street, NewCollege Building, 16th Floor, Philadelphia, PA 19102; e-mail: [email protected].

Financial DisclosureThe authors did not report any potential conflicts of interest.

© 2011 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/11

856 VOL. 117, NO. 4, APRIL 2011 OBSTETRICS & GYNECOLOGY

described more than a decade ago,7 there have beenno further attempts to evaluate current uses. Further-more, little is understood about the factors that areassociated with their use. The purposes of this studywere to determine if OTC and alternative medicineuse remains prevalent among women with chronicvaginitis and to evaluate which epidemiologic factorsare associated with greater use of these therapies.

MATERIALS AND METHODSThis prospective cohort study was approved by theDrexel University College of Medicine InstitutionalReview Board. Participants were recruited amongnew patients presenting to the Drexel UniversityVaginitis Referral Center between November 2004and February 2006 for the evaluation of chronicvulvovaginal symptoms. Patient care was provided bya board-certified gynecologist who had fellowshiptraining in infectious disease and a women’s healthnurse practitioner with more than a decade of expe-rience in treating women with chronic vaginal symp-toms. The center averages an estimated 3,500 returnand 500 new patient encounters each year.

Informed consent was obtained from each patientbefore enrollment in the study. The patients weregiven a self-administered questionnaire that evaluateda variety of factors, including demographic informa-tion, previous and current diagnoses, previous andcurrent medications, and medical and social history.In inquiring about past medications, the question-naires asked about specific OTC and CAM treat-ments and also asked open-ended questions to elicitinformation about medications not included in thelist. The questionnaire included the Center for Epide-miologic Studies Depression Scale,8 the Cohen Per-ceived Stress Scale (maximum score�56),9 and theJohn Henry scale (maximum score�60).10 As de-scribed elsewhere,11 a standardized evaluation proto-col was used to assign a diagnosis. In women withmultiple diagnoses, a primary diagnosis that cliniciansfelt accounted for the bulk of the symptoms wasassigned.

Patient information was analyzed to evaluaterelationships between patient characteristics and theOTC and alternative therapies used by the studypopulation. Different subgroups were then furtheranalyzed in demographic and background informa-tion, mental and physical health, duration and sever-ity of symptoms, and differing diagnoses to identifypotential differences between patients who used alter-native therapies and those who did not.

Data analysis was performed using Stata 10.1(StataCorp LP, College Station, TX). Continuous data

were compared using t tests, and nonparametricWilcoxon rank-sum tests were used for nonnormaldata. Normality was tested using the Kolmogrov-Smirnov test. Categorical data were analyzed using �2

tests. Fisher exact test was used when the predictednumbers in the cells were less than five. Variableswith missing data have a missing data category in thetable; however, the missing data were not imputedand were not used in the analysis. A multivariablelogistic regression was used to evaluate the adjustedodds of the demographic and clinical variables on theuse of alterative medicines in the sample. List-wisedeletion was used in the multivariable analysis, lead-ing to the model being performed for 404 cases.Statistical significance was set at the 0.05 level.

RESULTSA total of 481 patients enrolled in the study, and theirdemographics evaluated by CAM use are presentedin Table 1. The overall population was divided intotwo subgroups: those who had used CAM (n�312,64.9%) and those who had not (n�169, 35.1%). Forthe most part, the overall patient population consistedof white, well-educated, relatively wealthy women.Most (64.4%) were married or living with a partnerand reported an annual income of $40,000 or more(66%). Overall, 312 (64.9%) of women used at leastone CAM.

Compared with nonusers, patients using alterna-tive treatments tended to be younger than those whodid not (83.4% younger than 50 compared with73.1%; P�.032), with the highest percentage of usersin the 25- to 35-year-old age group (35.6%; n�112). Asmaller proportion of CAM users were noted to beAfrican American (11.9% compared with 21.3%;P�.018). A greater proportion of CAM users (58.1%compared with 53.2%) had college or graduate schooleducation, although this was not significant at the 0.05level. There was no statistically significant differencebetween CAM users and nonusers in work status,self-rated emotional health, history of a mental healthcondition, Center for Epidemiologic Studies Depres-sion Scale scores, or a history of medical, pain, orautoimmune conditions. Users of alternative thera-pies reported a significantly higher level of perceivedstress (mean 22.6, standard deviation 8.6) comparedwith nonusers (mean 20.3, standard deviation 8.4;P�.008, data not shown). When the perceived stressvariable was dichotomized at the 75th percentile, the Pvalue was significant only at the .10 level.

Table 2 presents the various CAM that they usedto self-treat their chronic vaginal symptoms. Among

VOL. 117, NO. 4, APRIL 2011 Nyirjesy et al Chronic Vaginitis 857

CAM that were used, the most frequent were yogurt(46.9%) and acidophilus pills (34.7%).

The duration, severity, and type of symptomspatients experienced were compared between the twogroups (Table 3). CAM users had higher interferencein their work (59.1% compared with 40.6%; P�.001)

or social life (57.9% compared with 40.2%; P�.001),greater discomfort in day-to-day activities, and hadbeen seen by more doctors (median 2 compared with1; P�.001). When the array of symptoms experiencedby patients was examined, there was no significantdifference in the patients’ reported primary symptombetween the two groups. However, when asked to listall the symptoms they found concerning, alternativetherapy users exhibited higher levels of discharge(55.8% compared with 39.1%; P�.001), itching(69.2% compared with 36.9%; P�.001), and burning(59.6% compared with 32.1%; P�.001) comparedwith nonusers.

Current and past diagnoses were compared (Ta-ble 4). Sixty-eight percent of CAM users and 32% ofnonusers reported a previous diagnosis of vulvovagi-nal candidiasis (P�.001). Patients using alternativetherapies were also significantly more likely to havebacterial vaginosis diagnosed (34.3% users comparedwith 24.8% nonusers; P�.033). Similarly, CAM userswere more likely to say that they had previouslyself-treated or been prescribed a medicine for vulvo-vaginal candidiasis (P�.02 and �.001, respectively).However, by the time they were seen at the DrexelVaginitis Center, there was no significant differencein the prevalence of actually having vulvovaginalcandidiasis or bacterial vaginosis between CAM usersand nonusers.

A multivariable logistic regression (Table 5) wasused to evaluate the adjusted odds of the factorsaffecting use of alternative therapies adjusting forsignificant factors at the 0.10 level from the univari-able comparisons. Variables that were not significantin the final model were removed if the removal didnot drastically affect the significance and effect of theother covariates. Women who had seen two or moredoctors compared with one or less for their symptomswere more likely to use alternative methods (oddsratio [OR] 2.35, 95% confidence interval [CI] 1.41–3.93). Women who reported moderate (OR 2.01, 95%

Table 1. Survey Population Demographics

Characteristic

CAM NotUsed

(n�167,35.1%)

CAMUsed

(n�312,64.9%) P

Age (y) .032Younger than 25 20 (11.9) 45 (14.4)25–35 43 (25.8) 112 (35.9)35–50 59 (35.3) 100 (32.1)Older than 50 45 (26.9) 55 (17.6)Missing 2 0

Race .018White 126 (75.0) 256 (82.1)African American 36 (21.3) 37 (11.9)Hispanic or other 7 (4.1) 19 (6.09)

Education .115High school or less 37 (23.9) 45 (14.7)Some college or

technical school36 (23.6) 83 (27.0)

College 46 (29.5) 101 (32.9)Graduate school 37 (23.7) 78 (25.4)Missing 13 5

Marital status .121Single 36 (22.6) 95 (30.9)Divorced, widowed,

separated15 (9.43) 20 (6.5)

Married 108 (67.9) 192 (62.5)Missing 10 5

Depression scale .164Not depressed 107 (70.4) 184 (61.3)Possibly depressed 23 (15.1) 59 (19.7)Probably depressed 22 (14.5) 57 (19)Missing 17 12

Cohen perceived stressMore than 75th

percentile34 (22.4) 90 (29.9) .090

Missing 17 11Income .226

Less than $25,000 27 (17.5) 32 (10.7)$25,000–$40,000 19 (12.3) 36 (12.0)More than $40,000 95 (61.7) 204 (68.2)Did not know 13 (8.4) 27 (9.0)Missing 15 13

Work .135Full-time 82 (52.6) 185 (61.3)Part-time 23 (14.7) 35 (11.6)School or training 7 (4.5) 20 (6.6)Retired, homemaker,

unemployed44 (28.2) 62 (20.5)

Missing 13 10

CAM, complementary and alternative medicine.Data are n (%) unless otherwise specified.

Table 2. Alternative Therapies Used by SurveyPopulation

Therapy n (%)

Yogurt 226 (46.9)Acidophilus pills 162 (34.7)Other health-food supplements 69 (14.4)Low-carbohydrate diet 63 (13.1)Garlic or garlic supplements 41 (8.5)Low-oxalate diet 27 (5.6)Acupuncture 22 (4.6)Glucosamine tablets 17 (3.5)

858 Nyirjesy et al Chronic Vaginitis OBSTETRICS & GYNECOLOGY

CI 1.14–3.55) and high (OR 2.92, 95% CI 1.32–6.45)interference to social life were more likely to usealternative therapies compared with women whoreported that the conditions affected their social lifesome or none of the time. Because of the highcorrelation between the interference in social life andinterference in work, only the former was added inthe regression model. Hispanic or women of anotherrace were more likely compared with African Amer-ican women to use alternative methods (OR 10.59,95% CI 1.88–59.63). White women also showed ahigher odds of using CAM compared with African

American women (OR 2.12, 95% CI 0.96–4.67), butit was not significant at the 0.05 level. Women whohad graduate school education had higher odds (OR1.94, 95% CI 0.90–4.19), although not significant atthe 0.05 level, to use CAM compared with womenwith high school or less than high school education.Women who had itching (OR 2.43, 95% CI 1.38–4.32) and burning (OR 2.01, 95% CI 1.13–3.57) weremore likely to use alternative therapies comparedwith those who did not present these symptoms.Women who had a previous diagnosis of yeast infec-tion were also more likely to use alternative therapies(OR 2.12, 95% CI 1.22–3.66).

DISCUSSIONThe presence of CAM in the landscape of modernhealth care is well-established and growing. Despitethis fact, it remains challenging to predict whichpatients will turn to alternative medicine and why.Several studies have sought to clarify the reasons thatpatients choose alternative therapies and demo-graphic factors that are associated with CAM use. A2004 study of patients with irritable bowel diseasefound that 60% of patients surveyed used CAM, andthese therapies were more common in older marriedwomen.12 There was no statistically significant associ-ation found between CAM use and education, em-ployment status, or several markers of disease sever-

Table 3. Duration, Type, and Severity ofSymptoms in Alternative-TherapiesPopulation

Characteristic

CAM NotUsed

(n�184,37.1%)

CAMUsed

(n�312,62.9%) P

Interferes with social life .001None 95 (59.8) 130 (42.1)Moderate or some 43 (27.0) 109 (35.3)All or most 21 (13.2) 70 (22.7)Missing 10 3

Interferes with work life .000None 96 (60.4) 124 (40.9)Slightly or moderately 46 (28.9) 113 (37.3)Quite a bit or extremely 17 (10.7) 66 (21.8)Missing 10 9

Discomfort in day-to-dayactivities

37.4�28.8 45.8�28.4 .002

Discomfort with sex 65.5�31.7 59.7�31.9 .070Duration of symptoms (y) .205

1 or less 51 (35.7) 100 (33.4)1–5 74 (51.8) 141 (47.2)More than 5 18 (12.6) 58 (19.4)Missing 26 13

Number of doctors seen 1 (0–11) 2 (0–13) �.001Number of times diagnosed 1 (0–15) 2 (0–75) �.001Primary symptom .120

Discharge 46 (29.9) 99 (33.6)Itching or irritation 50 (32.5) 114 (38.6)Burning or pain with sex 48 (31.2) 67 (22.7)Odor 5 (3.3) 12 (4.1)Lumps 5 (3.3) 3 (1.0)Missing 15 17

All symptomsDischarge 72 (39.1) 174 (55.8) �.001Itching 68 (36.9) 216 (69.2) �.001Burning 59 (32.1) 186 (59.6) �.001Pain 74 (40.2) 146 (46.8) .15Odor 40 (21.7) 94 (30.1) .04Soreness 91 (49.5) 196 (62.8) .004Lumps 15 (8.2) 26 (8.3) .94

CAM, complementary and alternative medicine.Data are n (%), mean�standard deviation, or median (range)

unless otherwise specified.

Table 4. Diagnosis in Alternative-TherapiesPopulation

Characteristic

CAM NotUsed

(n�184,37.1%)

CAMUsed

(n�312,62.9%) P

Diagnosis of or treatmentfor yeast in past

143 (90.5) 305 (98.4) �.001

Missing 11 2Treated yeast with over-the-

counter medicationsamong casesdiagnosed

99 (69.2) 243 (79.7) .02

Previous diagnosisUnsure 9 (4.9) 19 (6.1) .58Vulvodynia or vestibulitis 26 (14.1) 52 (16.7) .45Yeast 61 (33.2) 216 (69.2) �.001Bacterial vaginosis 42 (22.8) 107 (34.3) .007Other 26 (15.9) 21 (8.4) .02

Drexel MD diagnosisBacterial vaginosis 17 (9.24) 19 (6.09) .19Yeast 30 (16.3) 58 (18.6) .52Vestibulitis 20 (10.9) 38 (12.2) .66Other 93 (76.9) 164 (81.6) .31

CAM, complementary and alternative medicine.Data are n (%) unless otherwise specified.


ity. This is in contrast to other studies that have foundan association between CAM use and higher in-come.1,13–15

Among the conditions identified in studies ofCAM use, higher use was consistently associated withtreatment of chronic diseases such as back pain,anxiety, and depression. There is essentially no men-tion of gynecologic symptoms in these large surveys,even among those that focus only on female patients.One study included the disease category of “meno-pause” and found that although few women reportedusing alternative therapies for menopausal symptoms

(3%), women with menopausal symptoms were morelikely to report use of CAM for other symptoms (OR1.9).13 No survey studies that were identified, how-ever, described the use of alternative remedies forchronic vaginitis, one of the most common reasonswomen seek gynecologic care.

In an initial attempt to characterize the chronicvaginitis population and their self-treatment habits,we reported in 1997 that 41.9% of surveyed womenhad used an alternative remedy for vaginitis symp-toms in the preceding year.7 Thirteen years later, ourcurrent study found a much larger percentage ofpatients using CAM treatments for chronic vaginitis(64.9%). The demographics of the two study popula-tions are similar, although a direct comparison of thetwo studies is not possible because of differences inthe variables that were examined. It is interesting,however, to note that this growing trend in alternativetherapy use in this population is consistent withnational findings.

Many factors were identified as being signifi-cantly associated with CAM use, including patientage, race, level of perceived stress, previous diagnosisof candidiasis or bacterial vaginosis, greater interfer-ence with work and social life, discomfort in day-to-day activities, and number of doctors seen for evalu-ation of symptoms. Given the increased level of stressfound in the women who used alternative therapies, itprompts the question of whether patients who turn tothese methods have a greater sense of desperationcompared with those who use conventional treat-ments alone. It is reasonable to suggest that patientswith a chronic condition may turn to unprovenalternative methods if they are dissatisfied with con-ventional therapies or if they are reaching a greaterlevel of desperation in their search for symptomaticrelief or cure. There are essentially no studies thatassess the patient’s feeling of desperation in dealingwith a chronic condition and the subsequent use ofalternative therapies except one. A study examiningthe narrative experience of parents with a child withDown syndrome and their use of CAM treatmentsexamined the parents’ possible sense of desperationin the face of their child’s diagnosis.16 This studycounters that desperation is not so much a motivationfor using alternative therapies as the parents’ desire tobe active advocates for their children. It is unclear thatthis conclusion applies in the context of our patientschoosing to use alternative therapies for themselves.

The primary limitation of our study was its de-pendence on written questionnaires, which led toincomplete data for some patients and potential recallbias for all. In addition, because we cannot be certain

Table 5. Multiple Logistic Regression Model forAlternative-Therapy Use (n�401)

Variable

Odds Ratio(95% Confidence

Interval)

Number of doctors seenNone or 1 12 or more 2.35 (1.41, 3.93)

Age (y)Younger than 25 125–35 1.15 (0.46, 2.90)35–50 0.90 (0.34, 2.37)Older than 50 1.09 (0.38, 3.18)

RaceAfrican American 1White 2.12 (0.96, 4.68)Hispanic or other 10.60 (1.88, 59.64)

EducationHigh school or less 1Some college or technical school 1.80 (0.82, 3.95)College 1.24 (0.59, 2.65)Graduate school 1.94 (0.90, 4.20)

WorkFull time 1Part time 0.57 (0.25, 1.26)In school or training 0.68 (0.24, 2.09)Retired or other 0.59 (0.31, 1.13)

Interference with social lifeSome or none of the time 1Moderately 2.01 (1.14, 3.55)All or most of the time 2.92 (1.32, 6.45)

Marital statusMarried 1Divorced, widowed, separated 0.63 (0.23, 1.55)Single 1.27 (0.64, 2.52)

Stressed more than 75th percentile onCohen perceived stress scale

1.79 (1.00, 3.22)

Discharge 0.99 (0.54, 1.81)Itching 2.45 (1.38, 4.28)Burning 2.01 (1.13, 3.57)Pain 0.99 (0.57, 1.72)Odor 1.25 (0.65, 2.41)Soreness 0.78 (0.43, 1.39)Previous bacterial vaginosis 1.02 (0.55, 1.89)Previous yeast infection 2.12 (1.22, 3.66)

860 Nyirjesy et al Chronic Vaginitis OBSTETRICS & GYNECOLOGY

what conditions these patients had when their vaginalsymptoms initially began, we are unable to commenton the efficacy of any of the CAM that patients used.Finally, although the current patient diagnoses wereassigned by experienced providers with a specialexpertise in managing chronic vulvovaginal prob-lems, it is possible that there was potential misdiag-nosis in our patients at the time of evaluation. How-ever, the use of stringent criteria for diagnosis shouldhelp to allay this latter concern. Despite these limita-tions, our study shows that CAM use is common inwomen with chronic vaginitis, particularly in thosewho are young, have more disruptive symptoms, andreport greater stress. We feel that the results of ourstudy lead to a better understanding of what factorsmotivate women with chronic vaginitis to use alterna-tive treatments.

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