Can Fungal Infections Lead to Pelvic Inflammatory Disease and Infertility? - Obstetrics and Gynecology

Dr. Huang Jianzhong reply Obstetrics and Gynecology

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1.
I have been experiencing recurrent vaginal yeast infections for two years! On average, it occurs once a month.
Each time I have inflammation, I go to the gynecologist for an examination, and the doctor prescribes a week of oral antibiotics, suppositories, and ointments.
Usually, I feel cured after a week, but recently I have noticed that even after a week of treatment, I still do not feel completely healed.
So a few days ago, I returned for a follow-up, and the doctor said there is still a little bit left, and suggested changing the medication and prescribing another week of suppositories and ointments.
However, I just found information stating that long-term vaginal inflammation can lead to pelvic inflammatory disease and even infertility.
I plan to have children before I turn 30, so I am very worried that my frequent yeast infections might lead to infertility in the future.
I hope the doctor can explain this in detail and provide any suggestions for a permanent cure.
Also, does my boyfriend need to be treated for the yeast infection as well? I really find the recurrence very frustrating.

Answer: Treatment for recurrent vulvovaginal candidiasis (yeast infection) is important.
Candida fungi are present throughout the human body, including the mouth, intestines, and women's vaginas.
If Candida is found in the vagina without symptoms (which occurs in about 20% of cases), it does not require treatment, as it can be considered a normal vaginal flora.
However, when the concentration of Candida increases and causes symptoms such as itching, burning, vulvar redness, painful urination, or cracking, treatment is necessary.
Vulvovaginal candidiasis is not classified as a sexually transmitted infection, but it can be transmitted to sexual partners through sexual intercourse.
When men are infected, they may exhibit symptoms on the glans and other areas.
Therefore, when a woman has a yeast infection, her partner should also consider treatment, although studies suggest that treating the partner may not significantly benefit the woman.
The most common species causing vulvovaginal candidiasis is Candida albicans, accounting for about 80-90%, while other non-albicans species include C.
glabrata, C.
tropicalis, C.
parapsilosis, and C.
krusei.
Diagnosis can be assisted by examining vaginal secretions under a microscope for pseudohyphae (indicative of C.
albicans) or spores (often non-albicans), but the sensitivity of microscopy is only 50-80%.
Culture or PCR (polymerase chain reaction) testing is more definitive.
Approximately 70-75% of women will experience a yeast infection in their lifetime, with 5-8% experiencing recurrent vulvovaginal candidiasis, defined as having symptoms four or more times a year, which is quite distressing for women.

There are many medications available for treating yeast infections, including both vaginal and oral options.
Currently, fluconazole is the most effective, convenient, and has fewer side effects, requiring only one dose per week, making it the standard treatment.
However, chronic recurrent cases may require this medication for several months or even up to a year.
Fluconazole is a semi-synthetic azole that can be taken orally or intravenously.
After oral administration, peak blood concentration is reached within 1-2 hours, with a bioavailability of over 80% and a long half-life (average 31.6 hours).
A single oral dose of 150 mg fluconazole results in a plasma concentration of 2.82 µg/mL after seven days (the minimum inhibitory concentration for C.
albicans is 0.39 µg/mL), allowing for weekly dosing.
However, higher doses may be needed for non-albicans species.
Fluconazole acts as a fungistatic agent, but some reports suggest it may have fungicidal properties.
Most of it (60-75%) is excreted through the kidneys, with some through feces.
It is classified as a Category C drug during pregnancy.

Acute treatment literature shows that oral fluconazole is effective for acute vulvovaginal candidiasis.
A study by Zhao et al.
involving 24 patients with vulvovaginal candidiasis found that 14 (58.3%) had C.
albicans, while 9 (37.5%) had non-albicans species, and one (4.2%) had both C.
albicans and C.
glabrata.
All were treated with a single oral dose of 150 mg fluconazole, and after 28-38 days, 21 patients (87.5%) were clinically effective, with 3 failures (12.5%), including one case of C.
parapsilosis and two of C.
glabrata.
Sekhavat et al.
treated 72 women with acute vulvovaginal candidiasis with a single oral dose of 150 mg fluconazole, and after seven days, 61 (84.7%) were clinically cured, with 58 (80.5%) showing negative fungal tests.
After 30 days, only one patient had clinical symptoms of a yeast infection, indicating that a single oral dose of fluconazole is very effective for treating vulvovaginal candidiasis.

For chronic disease treatment, a study by Sobel in 2004 noted that recurrent vulvovaginal candidiasis is difficult to cure, so a six-month continuous treatment was attempted for better outcomes.
The study included women aged 18 and older who had experienced 24 or more yeast infections in the past year and had current acute candidiasis.
Exclusion criteria included pregnancy, mixed infections, HIV infection, or recent antifungal use.
The treatment protocol began with fluconazole 150 mg, repeated after 72 hours for a total of three doses as induction therapy.
After 14 days, patients returned for vaginal culture, and only those with negative cultures were considered clinically cured.
Patients were then divided into two groups: one received weekly oral fluconazole 150 mg, while the other received a placebo for six months, with follow-ups at 9 and 12 months.
A total of 494 patients were enrolled, with 427 having positive cultures, predominantly C.
albicans (401 cases, 93.9%).
After six months, the fluconazole group had a cure rate of 90.8% (128/141), while the placebo group had a cure rate of 35.9% (51/142), showing a statistically significant difference (p<0.001).
At the nine-month follow-up, the recurrence rate in the fluconazole group was 26.8% (26/97), compared to 72.2% (96/133) in the placebo group, also statistically significant (p<0.001).
At the 12-month follow-up, the recurrence rate was 57.1% (72/126) in the fluconazole group versus 78.1% (107/157) in the placebo group (p<0.001).
Side effects were mostly mild, including gastrointestinal symptoms, headaches, and rashes, with minimal impact on liver function.
Only one patient experienced a slight increase in aminotransferase levels (<1%), which did not affect continued treatment.
The authors concluded that weekly oral fluconazole for six months effectively prevents recurrent infections, but the recurrence rate remains high at 57.1% after stopping treatment for six months, indicating difficulty in achieving long-term cure rates.
The average fluconazole usage in this study was 3.9 g.
For one-year treatment, following Sobel's 2004 study, Donders et al.
developed a one-year fluconazole regimen, maintaining the total dosage but extending the intervals between doses to observe effects.
The inclusion and exclusion criteria were similar to Sobel's study, with the additional requirement of no diabetes and no allergy to fluconazole.
The treatment began with fluconazole 200 mg, repeated every other day for a total of three doses (e.g., days 1, 3, 5 or 2, 4, 6).
After 14 days, patients returned for evaluation; if symptoms resolved or cultures were negative, they entered the first maintenance phase, which involved weekly oral fluconazole 200 mg for four weeks.
If still asymptomatic or with negative cultures, they entered the second maintenance phase, taking fluconazole 200 mg every two weeks for four months.
If still asymptomatic or with negative cultures, they entered the third maintenance phase, taking fluconazole 200 mg monthly for six months.
If symptoms recurred or cultures were positive, they repeated the third maintenance phase for a total of one year.
Patients returned for follow-up three months after stopping treatment.
Among 136 enrolled patients with recurrent vulvovaginal candidiasis, 19 withdrew due to negative cultures, loss to follow-up, or refusal to continue.
Ultimately, 117 patients completed maintenance treatment.
Results showed a cure rate of 90% (101/117) at six months, 70% (90/117) at 12 months, and 64% (72/117) at 18 months, with no serious side effects reported.
The average fluconazole usage in this study was 4 g.

From the above reports, it can be seen that reducing fluconazole dosage and extending the intervals between doses may yield better treatment outcomes.
In conclusion, recurrent vulvovaginal candidiasis is a distressing condition for women, often causing itching and discomfort that affects daily activities, and treatment can be challenging.
Oral fluconazole appears to be an ideal medication due to its convenience, effectiveness, and low side effects, requiring administration weekly or less frequently.
However, resistance rates for non-albicans species are higher, potentially necessitating increased dosages.
Therefore, physicians should understand that, in addition to avoiding various potential pathogenic factors, it may be beneficial to start with higher doses initially, followed by treatment for six months, one year, or even longer.
2.
Six months ago, I experienced a delayed menstrual period of one week.
To be cautious, I wondered if I might be pregnant, so I went to the gynecologist to get medication to induce my period.
The doctor also performed an ultrasound to check for any issues and unexpectedly found a tumor on my right ovary, which was already six centimeters.
The doctor recommended surgery, and I subsequently underwent laparoscopic surgery to remove the tumor.
The biopsy result was a chocolate cyst, and after the surgery, the doctor advised me to take medication for six months to reduce the chance of recurrence.
I just finished the medication a few days ago, and the doctor scheduled a follow-up ultrasound on March 1 to check on my recovery.
I would like to ask the doctor if taking this medication could lead to increased vaginal inflammation or make it harder to treat?
Answer: No, it will not.
3.
Is it true that chocolate cysts are very likely to recur?
Answer: Some are.
4.
During the internal examination for inflammation, another doctor asked me if there was a problem with my ovary.
I told him I had a chocolate cyst removed, but after he spoke, I felt scared, wondering if he saw something abnormal.
Could it be that he noticed a recurrence, or is it just that the ovary looks different because I had surgery?
Answer: He was just asking.

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Reply Date: 2017/02/17