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R D Catterallcandidosis.

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B r i t . J . v e n e r . D i s . ( 1 9 7 1 ) 4 7 , 4 5

I n f l u e n c e o f g e s t o g e n i c c o n t r a c e p t i v e p i l l s on

v a g i n a l c a n d i d o s i s

R . D . CATTERALL

James P r i n g l e H o u s e , T h e M i d d l e s e x H o s p i t a l , L o n d o n , W . 1 .

The u s e o f a n t i o v u l a t o r y c o n t r a c e p t i v e p i l l s h a s i n -

c r e a s e d r a p i d l y i n r e c e n t y e a r s a n d t h e W o r l d H e a l t hO r g a n i s a t i o n e s t i m a t e s t h a t t h e y a r e b e i n g t a k e n b y

m o r e t h a n 2 0 m i l l i o n women t h r o u g h o u t t h e w o r l d .

I n B r i t a i n , t h e C o m m i t t e e o n t h e S a f e t y o f D r u g s

h a s s t a t e d t h a t c o n t r a c e p t i v e p i l l s a r e e m p l o y e d b y

o v e r a m i l l i o n a n d a h a l f women a t t h e p r e s e n t t i m e .The i n c r e a s i n g u s e o f t h e s e p r e p a r a t i o n s h a s b e e n

f o l l o w e d b y a c o r r e s p o n d i n g i n c r e a s e i n t h e number o f

s i d e - e f f e c t s a t t r i b u t e d t o t h e m ; s o m e h a v e b e e n

s e r i o u s a n d a number o f d e a t h s h a v e b e e n r e p o r t e d .T h i s p a p e r p r e s e n t s f u r t h e r i n f o r m a t i o n a b o u t t h e

r e l a t i o n s h i p b e t w e e n g e s t o g e n i c c o n t r a c e p t i v e p i l l sa n d v a g i n a l c a n d i d o s i s . A l t h o u g h t h i s i s u s u a l l y a

b e n i g n c o m p l i c a t i o n , i t may l e a d t o d i s t r e s s i n g s y m p -t o m s , a n d on r a r e o c c a s i o n s t o s e r i o u s s y s t e m i c

m a n i f e s t a t i o n s . The c o n d i t i o n c a n b e p a s s e d t o men

a t s e x u a l i n t e r c o u r s e , when i t u s u a l l y r e s u l t s i nb a l a n o p o s t h i t i s .

C a n d i d a a l b i c a n s i s a f a c u l t a t i v e p a t h o g e n . I t s

p a t h o g e n i c i t y d e p e n d s n o t o n l y o n t h e s i z e o f t h e

c o l o n i e s , b u t a l s o on t h e t o l e r a n c e o f t h e h o s t t i s s u e st o i t . T h e r e i s e v i d e n c e t h a t t h e m u c o s a o f t h e m o u t h ,

i n t e s t i n e s , a n d v a g i n a c a n s h o w a m a r k e d t o l e r a n c e

t o t h e f u n g u s , w h e r e a s i t i s p r o b a b l e t h a t i t u s u a l l yc a u s e s s y m p t o m s when f o u n d on t h e s k i n o r e l s e w h e r e

( K o z i n n a n d T a s c h d j i a n , 1 9 6 6 ) . A c h a n g e i n t h et i s s u e s o r t h e m e t a b o l i s m o f t h e h o s t may d i s t u r b t h e

e q u i l i b r i u m a n d l e a d t o t h e d e v e l o p m e n t o f s y m p -

t o m s .

T h e r e i s g e n e r a l a g r e e m e n t t h a t t h e i n c i d e n c e o f

v a g i n a l c a n d i d o s i s i s i n c r e a s i n g i n many c o u n t r i e sa n d t h e c o n d i t i o n i s b e i n g d i a g n o s e d more f r e q u e n t l y( P u m p i a n s k i a n d S h e s k i n , 1 9 6 5 ) . C a n d i d a a l b i c a n sh a s now r e p l a c e d T r i c h o m o n a s v a g i n a l i s a s t h e

commonest c a u s e o f g e n i t a l s y m p t o m s i n women a n d

i t i s p r o b a b l y t h e p a t h o g e n f o u n d most f r e q u e n t l yi n t h o s e c o m p l a i n i n g o f v a g i n a l d i s c h a r g e .

F o r e x a m p l e , a t J a m e s P r i n g l e House o f t h e

M i d d l e s e x H o s p i t a l i n 1 9 6 5 , t h e r a t i o o f c a s e s o f

R e c e i v e d f o r p u b l i c a t i o n J u n e 4 , 1 9 7 0

t r i c h o m o n a l v a g i n i t i s t o c a s e s o f v a g i n a l c a n d i d o s i s

w a s t w o t o o n e a m o n g s t a l l t h e women c o m p l a i n i n go f g e n i t a l s y m p t o m s a n d t h r e e t o o n e a m o n g s t t h o s e

c o m p l a i n i n g s p e c i f i c a l l y o f v a g i n a l d i s c h a r g e . By

1 9 6 9 t h e r a t i o s h a d c h a n g e d c o m p l e t e l y , s o t h a t f o ra l l t h e women w i t h g e n i t a l s y m p t o m s t h e r a t i o w a s

o n e t o t h r e e a n d f o r t h o s e c o m p l a i n i n g o f v a g i n a l

d i s c h a r g e i t w a s o n e t o t w o ( T a b l e I ) .

TABLE I C h a n g e i n r a t i o o f T r i c h m o n a s t o C a n d i d a

Y e a r 1 9 6 5 1 9 6 9

A l l p a t i e n t s w i t h g e n i t a l s y m p t o m s 2 t o 1 1 t o 3

P a t i e n t s w i t h v a g i n a l d i s c h a r g e 3 t o 1 1 t o 2

Many o f t h e commoner c o n d i t i o n s w h i c h f a v o u r

t h e d e v e l o p m e n t o f C a n d i d a a l b i c a n s i n t h e v a g i n a

a r e w e l l known ( T a b l e I I ) . I n B r i t a i n , t h e m o s t

i m p o r t a n t a r e p r e g n a n c y , d i a b e t e s m e l l i t u s , a n t i -b i o t i c t h e r a p y , s t e r o i d t h e r a p y , a n d t h e u s e o f a n t i -t r i c h o m o n a l a g e n t s . E v i d e n c e t h a t g e s t o g e n i c p i l l s

p l a y a n i m p o r t a n t r o l e i n t h e r e c e n t i n c r e a s e i n i n c i -d e n c e o f v a g i n a l c a n d i d o s i s h a s b e e n p u t f o r w a r d b y

a number o f a u t h o r s . B o u r g ( 1 9 6 4 ) o b s e r v e d t h a t s i xo f s i x t y p a t i e n t s t a k i n g c o n t r a c e p t i v e p i l l s d e v e l o p e d

v a g i n a l c a n d i d o s i s . G a r d n e r ( 1 9 6 5 ) s t a t e d t h a t h a l f

h i s p a t i e n t s w i t h v a g i n a l c a n d i d o s i s w e r e u s i n g t h e s e

TABLE I I F a c t o r s f a v o u r i n g t h e d e v e l o p m e n t o fc a n d i d o s i s

1 . P h y s i o l o g i c a l f a c t o r s , e . g . p r e g n a n c y , e a r l y i n f a n c y

2 . S k i n d i s e a s e s , m a c e r a t i o n , a n d wounds3 . E n d o c r i n e d i s o r d e r s , e . g . d i a b e t e s m e l l i t u s , h y p o t h y r o i d i s m ,

h y p o p a r a t h y r o i d i s m , A d d i s o n ' s d i s e a s e ,a n d p a n c r e a t i t i s

4 . U n d e r n o u r i s h m e n t5 . D i s o r d e r s o f a b s o r p t i o n6 . A n t i b i o t i c t h e r a p y7 . S t e r o i d t h e r a p y8 . B l o o d d y s c r a s i a s , e . g . a c u t e l e u k a e m i a , a g r a n u l o c y t o s i s , a n d

a p l a s t i c a n a e m i a

9 . S u r g i c a l o p e r a t i o n s

1 0 . M a l i g n a n t d i s e a s e s a n d c y t o t o x i c a g e n t s1 1 . A n t i t r i c h o m o n a l a g e n t s

1 2 . C o n t r a c e P t i v e p i l l s

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4 6 B r i t i s h J o u r n a l o f V e n e r e a l D i s e a s e s

p r e p a r a t i o n s a n d t h o u g h t t h a t t h e r e c e n t i n c r e a s ei n t h e i n c i d e n c e o f t h e c o n d i t i o n was a l m o s t e n t i r e l yd u e t o a n t i o v u l a t o r y c o n t r a c e p t i v e s . W a l s h , H i l d e -

b r a n d t , a n d P r y s t o w s k y ( 1 9 6 5 ) d e m o n s t r a t e d C a n d i d a

i n twenty-two o f t w e n t y - f o u r p a t i e n t s u s i n g c o n t r a -

c e p t i v e p i l l s a n d Y a f f e e a n d G r o t s ( 1 9 6 5 ) f o u n d t h a tt h e y c o u l d c u r e t h e i r p a t i e n t s o f v a g i n a l c a n d i d o s i s

o n l y b y d i s c o n t i n u i n g t h e p i l l s . P o r t e r a n d

L y l e ( 1 9 6 6 ) t r e a t e d t h i r t e e n p a t i e n t s w i t h c a n d i d o s i s ,who were u s i n g o r a l c o n t r a c e p t i v e p i l l s ; most o f

them r e q u i r e d t wo or t h r e e courses o f n y s t a t i n t o

c l e a r t h e c o n d i t i o n an d i n t h r e e cases i t was necessary

t o d i s c o n t i n u e t h e p i l l s b e f o r e c u r e c o u l d b e a c h i e v e d .

C a t t e r a l l ( 1 9 6 6 ) d e s c r i b e d s i x women whose symp-

toms f i r s t a p p e a r e d a b o u t 9 months a f t e r s t a r t i n g t o

t a k e c o n t r a c e p t i v e p i l l s . H e a l s o d e s c r i b e d f o u r men

who p r e s e n t e d w i t h b a l a n o p o s t h i t i s due t o C a n d i d a

a l b i c a n s ; a l l o f t h e i r s e x u a l p a r t n e r s we r e f o u n d t o

h a v e v a g i n a l c a n d i d o s i s and had b e e n t a k i n g p i l l sf o r 6 t o 1 2 m o n t h s . These f i n d i n g s w e r e c o n f i r m e d

b y R i e t h ( 1 9 6 7 ) , wh o d e s c r i b e d p e n i l e symptoms

a f t e r c o i t u s i n a man whose p a r t n e r was found t o

h a v e v a g i n a l c a n d i d o s i s an d had been t a k i n g p i l l sf o r 1 0 m o n t h s .

H o w e v e r , M o r r i s an d M o r r i s ( 1 9 6 7 , 1 9 6 9 ) were

u n a b l e t o d e m o n s t r a t e a r e l a t i o n s h i p between o r a l

c o n t r a c e p t i v e s an d t h e i n c i d e n c e o f C a n d i d a a l b i c a n s

i n t h e v a g i n aor

any o t h e r c h a n g e i nt h e

v a g i n a lf l o r a .G a r d n e r ( 1 9 6 5 ) b e l i e v e d t h a t t h e hormonal c h a n g e s

i n d u c e d b y g e s t o g e n i c c o n t r a c e p t i v e p i l l s correspon-

d e d c l o s e l y t o t h o s e o f pregnancy an d r e g a r d e d t h e

r e s u l t i n g s t a t e o f t h e p a t i e n t as ' p s e u d o p r e g n a n c y ' .

As i n a t r u e pregnancy t h e g l y c o g e n content o f t h e

v a g i n a l mucosa was i n c r e a s e d . This l e d t o t h e g r o w t h

o f l a c t o b a c i l l i , which c o n v e r t e d t h e g l y c o g e n i n t o

l a c t i c a c i d . T he i n c r e a s e d g l y c o g e n , t h e presence o f

l a c t i c a c i d , and t h e c h a n g e i n t h e pH o f t h e v a g i n a

were t h o u g h t t o promote t h e g r o w t h o f C a n d i d a

a l b i c a n s and t h e v a g i n a was c o n s i d e r e d t o become t h e

i d e a l c u l t u r e m e d i u m f o r C a n d i d a . Cohen ( 1 9 6 9 )d e m o n s t r a t e d t h a t women w i t h a low v a g i n a l pHwere more l i a b l e t o i n f e c t i o n and a t t r i b u t e d t h i s t o

e x c e s s i v e d e s q u a m a t i o n o f t h e e p i t h e l i u m c a u s i n g a

b r e a k i n t h e c o n t i n u i t y o f t h e v a g i n a l m ucosa.

Wynn and Doar ( 1 9 6 6 ) d e m o n s t r a t e d a r e d u c t i o n

i n g l u c o s e t o l e r a n c e i n women t a k i n g o r a l c o n t r a -

c e p t i v e p i l l s . They l a t e r s u g g e s t e d t h a t t h e i m p a i r e d

g l u c o s e t o l e r a n c e was a t y p e o f ' s t e r o i d d i a b e t e s '

c a u s e d b y e l e v a t e d p l a s m a c o r t i s o l l e v e l s s e c o n d a r y

t o t h e o e s t r o g e n component o f t h e o r a l c o n t r a c e p t i v e

(Wynn and D o a r , 1 9 6 9 ) . They were u n a b l e t o pre-

d i c t w h i c h women were l i k e l y t o d e v e l o p s e r i o u s

i m p a i r m e n t o f g l u c o s e t o l e r a n c e an d c o u l d o n l y

s p e c u l a t e whether t h e i m p a i r e d g l u c o s e t o l e r a n c e an d

r a i s e d p l a s m a i n s u l i n l e v e l s m i g h t i n c r e a s e t h e r a t e o f

d e v e l o p m e n t o f c l i n i c a l d i a b e t e s m e l l i t u s a n d o f

a t h e r o s c l e r o s i s . S p e l l a c y ( 1 9 69 ) r e v i e w e d t h e e v i d e n c e

o f i m p a i r e d o r a l a n d i n t r a v e n o u s g l u c o s e t o l e r a n c ea n d t h e c h a n g e s i n t h e c i r c u l a t i n g l e v e l s o f o t h e r

c o m p o u n d s r e l a t e d t o g l u c o s e t o l e r a n c e , i n c l u d i n g

i n s u l i n , n o n - e s t e r i f i e d f a t t y a c i d , a n d p y r u v a t e .

A n a n a l y s i s o f t h e r e c o r d s o f 2 0 0 women a t t e n d i n g

J a m e s P r i n g l e H o u s e a t t h e M i d d l e s e x H o s p i t a l a n d

f o u n d t o h a v e v a g i n a l c a n d i d o s i s , s h o w e d t h a t 9 9

w e r e t a k i n g c o n t r a c e p t i v e p i l l s , 2 2 h a d r e c e n t l yb e e n p r e s c r i b e d b r o a d - s p e c t r u m a n t i b i o t i c s , t w e l v e

w e r e p r e g n a n t , a n d t e n h a d t a k e n a c o u r s e o f a n t i -t r i c h o m o n a l a g e n t s , s h o r t l y b e f o r e t he d i a g n o s i s o f

c a n d i d o s i s w a s m a d e . Two p a t i e n t s w e r e f o u n d t o

h a v e d i a b e t e s . No c a u s e c o u l d b e f o u n d f o r t h ec o n d i t i o n i n 5 5 p a t i e n t s ( T a b l e I I I ) .

T A B L E I I I 2 0 0 p a t i e n t s w i t h v a g i n a l c a n d i d o s i s

C o n t r a c e p t i v e p i l l s 9 9

B r o a d - s p e c t r u m a n t i b i o t i c s 2 2

P r e g n a n c y 1 2

A n t i t r i c h o m o n a l a g e n t s 1 0

D i a b e t e s 2

C a u s e unknown 5 5

T o t a l 2 0 0

Oft h e

f a c t o r sknown

t of a v o u r t h e

d e v e l o p m e n t o fc a n d i d o s i s , p r e g n a n c y , d i a b e t e s m e l l i t u s , r e c e n t

a n t i b i o t i c t h e r a p y , a n t i t r i c h o m o n a l a g e n t s , a n d o r a lc o n t r a c e p t i v e p i l l s a r e p r o b a b l y t h e m o s t i m p o r t a n t

i n t h e a e t i o l o g y o f v a g i n a l c a n d i d o s i s . The b a l a n c e

o f c l i n i c a l e v i d e n c e s u g g e s t s t h a t t h e r e i s a r e l a t i o n -s h i p b e t w e e n t h e u s e o f g e s t o g e n i c p i l l s a n d t h e

d e v e l o p m e n t o f v a g i n a l c a n d i d o s i s a n d t h i s a s s o c i a -t i o n i s s u p p o r t e d b y t h e e x p e r i m e n t a l w o r k i n d i c a t i n ga n a l t e r a t i o n i n g l u c o s e m e t a b o l i s m , a n i n c r e a s e i nt h e s e r u m b i n d i n g o f i n s u l i n , a n d a n a b n o r m a l

g l u c o s e t o l e r a n c e c u r v e , a s w e l l a s t h e c h a n g e s i n t h e

pH o f t h e v a g i n a .

A l t h o u g h t h e c o n d i t i o n c a n u s u a l l y b e c o n t r o l l e db y n y s t a t i n p e s s a r i e s , i n s o m e c a s e s i t i s n e c e s s a r y t os t o p t h e u s e o f t h e p i l l t o p r o d u c e r e l i e f f r o m t h e

s y m p t o m s a n d t o c u r e t h e p a t i e n t .

Summary and c o n c l u s i o n s

( 1 ) A r e v i e w o f t h e l i t e r a t u r e i n d i c a t e s t h a t t h e r e i sp r o b a b l y a c a u s a l r e l a t i o n s h i p b e t w e e n t h e u s e o f

g e s t o g e n i c c o n t r a c e p t i v e p i l l s a n d t h e d e v e l o p -

ment o f v a g i n a l c a n d i d o s i s .( 3 ) T h i s v i e w i s s u p p o r t e d b y r e c e n t e x p e r i m e n t a l

e v i d e n c e o f c h a n g e s i n g l u c o s e m e t a b o l i s m a n d i nv a g i n a l pH i n women t a k i n g c o n t r a c e p t i v e p i l l s .

( 3 ) A c h a n g e i n t h e r a t i o o f p a t i e n t s w i t h t r i c h o m o n a l

v a g i n i t i s a n d v a g i n a l c a n d i d o s i s i n r e c e n t y e a r s

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G e s t o g e n i c c o n t r a c e p t i v e p i l l s a n d v a g i n a l c a n d i d o s i s 4 7

a n d a n a n a l y s i s o f c a u s a t i v e f a c t o r s a m o n g s t

women w i t h v a g i n a l c a n d i d o s i s s u g g e s t t h a t o r a lc o n t r a c e p t i v e p i l l s a r e now t h e commonest c a u s e

o f t h e c o n d i t i o n .

R e f e r e n c e sB O U R G , R . ( 1 9 6 4 ) B u l l . A c a d . r o y . M i d . B e l g . , 7 s e r . , 4 ,

6 9 9

C A T T E R A L L , R . D . ( 1 9 6 6 ) L a n c e t , 2 , 8 3 0

C O H E N , L . ( 1 9 6 9 ) B r i t . J 7 . v e n e r . D i s . , 4 5 , 2 4 1

G A R D N E R , H . L . ( 1 9 6 5 ) A n t i b i o t . N e w s , 2 3 , 1 .K O Z I N N , P . J . , a n d T A S C H D J I A N , C . L . ( 1 9 6 6 ) J . A m e r .

m e d . A s s . , 1 9 8 , 1 7 0

M O R R I S , C . A . , a n d M o R R i s , D . F . ( 1 9 6 7 ) J . c l i n . P a t h . ,2 0 , 6 3 6

-, ( 1 9 6 9 ) B r i t . m e d . J 7 . , 1 , 3 1 9

P O R T E R , P . S . , a n d L Y L E , J . S . ( 1 9 6 6 ) A r c h . D e r m . , 9 3 , 4 0 2P U M P I A N S K I , R . , a n d S H E S K I N , J . ( 1 9 6 5 ) D e r m a t o l o g i c a

( B a s e l ) , 1 3 1 , 4 4 6

R I E T H , H . ( 1 9 6 7 ) M y k o s e n , 1 0 , 1 5 1

S P E L L A C Y , W. N . ( 1 9 6 9 ) A m e r . J 7 . O b s t e t . G y n e c . , 1 0 4 , 4 4 8

W A L S H , H . , H I L D E B R A N D T , R . J . , a n d P R Y S T O W S K Y , H .

( 1 9 6 8 ) I b i d . , 1 0 1 , 9 9 1 .

WYNN, V . , a n d D o A R , J . W. H . ( 1 9 6 6 ) L a n c e t , 2 , 7 1 5

, _ ( 1 9 6 9 ) I b i d . , 2 , 7 6 1

Y A F F E E , H . S . , a n d G R O T S , I . ( 1 9 6 5 ) New E n g l . J . Med2 7 2 , 1 2

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