Nyirjesy, Paul MD; Robinson, Jennifer MD, MPH; Mathew, Leny MS; Lev-Sagie, Ahinoam MD; Reyes, Ingrid MD; Culhane, Jennifer F. PhD
OBJECTIVES: To describe the use of complementary alternative medicines in women with chronic vaginitis and to evaluate epidemiologic factors associated with these treatments.
METHODS: In this prospective cohort study, patients with chronic vaginitis completed a questionnaire about past diagnoses and treatments. Information regarding demographics, medical and social history, perceived mental and emotional stress, and current symptoms was collected. All patients underwent a standard physical examination and laboratory testing and were assigned a specific diagnosis.
RESULTS: A total of 481 women were enrolled; 64.9% used complementary alternative medicines. The most common treatments were yogurt and acidophilus pills. In univariate analysis, compared with nonusers, users of complementary 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 interfered with 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 had seen more doctors (median 2 compared with 1; P<.001) and were more likely to report a history of vulvovaginal candidiasis (98.4% compared with 90.5%; P<.001) or bacterial vaginosis (34.3% compared with 22.8%; P=.007). In the multivariable analysis, interference with social life, higher number of doctors seen, symptoms of itching or burning, and previous diagnoses of yeast infection remained associated with alternative medicine use. A current diagnosis of vulvovaginal candidiasis was not associated with alternative medicine use.
CONCLUSION: Complementary alternative medicine use is common in women with chronic vaginitis, particularly in those who are young, have more disruptive symptoms, and report greater stress.
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 in the United States. The National Institutes of Health has found that 38% of the adult population in the United States uses some form of CAM.1 CAM therapies also are often used in the treatment of chronic conditions as opposed to acute or life-threatening illness, and a significant number of patients do not disclose their use of CAM to their conventional physicians.2 A common situation in which gynecologists may encounter patients using alternative therapies is in the treatment of chronic vaginitis. Vaginitis remains one of the most common reasons for a woman to visit her gynecologist, but patients also have the option of self-treatment with widely available over the counter (OTC) antimycotic or alternative therapies.3 Although a woman's ability to accurately self-diagnose vulvovaginal candidiasis has been called into question,4 the use of these products has sky-rocketed, with an estimated $275 million spent annually just on OTC antifungal agents.5 Alternative therapies that are commonly used for vaginitis include probiotics, boric acid, douching, tea tree oil, and garlic.6
Although the extent of use of alternative medicines in women with chronic vaginitis has been described more than a decade ago,7 there have been no further attempts to evaluate current uses. Furthermore, little is understood about the factors that are associated with their use. The purposes of this study were to determine if OTC and alternative medicine use remains prevalent among women with chronic vaginitis and to evaluate which epidemiologic factors are associated with greater use of these therapies.
MATERIALS AND METHODS
This prospective cohort study was approved by the Drexel University College of Medicine Institutional Review Board. Participants were recruited among new patients presenting to the Drexel University Vaginitis Referral Center between November 2004 and February 2006 for the evaluation of chronic vulvovaginal symptoms. Patient care was provided by a board-certified gynecologist who had fellowship training in infectious disease and a women's health nurse practitioner with more than a decade of experience in treating women with chronic vaginal symptoms. The center averages an estimated 3,500 return and 500 new patient encounters each year.
Informed consent was obtained from each patient before enrollment in the study. The patients were given a self-administered questionnaire that evaluated a variety of factors, including demographic information, previous and current diagnoses, previous and current medications, and medical and social history. In inquiring about past medications, the questionnaires asked about specific OTC and CAM treatments and also asked open-ended questions to elicit information about medications not included in the list. The questionnaire included the Center for Epidemiologic Studies Depression Scale,8 the Cohen Perceived Stress Scale (maximum score=56),9 and the John Henry scale (maximum score=60).10 As described elsewhere,11 a standardized evaluation protocol was used to assign a diagnosis. In women with multiple diagnoses, a primary diagnosis that clinicians felt accounted for the bulk of the symptoms was assigned.
Patient information was analyzed to evaluate relationships between patient characteristics and the OTC and alternative therapies used by the study population. Different subgroups were then further analyzed in demographic and background information, mental and physical health, duration and severity of symptoms, and differing diagnoses to identify potential differences between patients who used alternative 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 nonparametric Wilcoxon rank-sum tests were used for nonnormal data. Normality was tested using the Kolmogrov-Smirnov test. Categorical data were analyzed using χ2 tests. Fisher exact test was used when the predicted numbers in the cells were less than five. Variables with missing data have a missing data category in the table; however, the missing data were not imputed and were not used in the analysis. A multivariable logistic regression was used to evaluate the adjusted odds of the demographic and clinical variables on the use of alterative medicines in the sample. List-wise deletion was used in the multivariable analysis, leading to the model being performed for 404 cases. Statistical significance was set at the 0.05 level.
A total of 481 patients enrolled in the study, and their demographics evaluated by CAM use are presented in Table 1. The overall population was divided into two subgroups: those who had used CAM (n=312, 64.9%) and those who had not (n=169, 35.1%). For the most part, the overall patient population consisted of white, well-educated, relatively wealthy women. Most (64.4%) were married or living with a partner and reported an annual income of $40,000 or more (66%). Overall, 312 (64.9%) of women used at least one CAM.
Compared with nonusers, patients using alternative treatments tended to be younger than those who did not (83.4% younger than 50 compared with 73.1%; P=.032), with the highest percentage of users in the 25- to 35-year-old age group (35.6%; n=112). A smaller proportion of CAM users were noted to be African 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 school education, although this was not significant at the 0.05 level. There was no statistically significant difference between CAM users and nonusers in work status, self-rated emotional health, history of a mental health condition, Center for Epidemiologic Studies Depression Scale scores, or a history of medical, pain, or autoimmune conditions. Users of alternative therapies reported a significantly higher level of perceived stress (mean 22.6, standard deviation 8.6) compared with nonusers (mean 20.3, standard deviation 8.4; P=.008, data not shown). When the perceived stress variable was dichotomized at the 75th percentile, the P value was significant only at the .10 level.
Table 2 presents the various CAM that they used to self-treat their chronic vaginal symptoms. Among CAM that were used, the most frequent were yogurt (46.9%) and acidophilus pills (34.7%).
The duration, severity, and type of symptoms patients experienced were compared between the two groups (Table 3). CAM users had higher interference in 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 had been seen by more doctors (median 2 compared with 1; P<.001). When the array of symptoms experienced by patients was examined, there was no significant difference in the patients' reported primary symptom between the two groups. However, when asked to list all the symptoms they found concerning, alternative therapy 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) compared with nonusers.
Current and past diagnoses were compared (Table 4). Sixty-eight percent of CAM users and 32% of nonusers reported a previous diagnosis of vulvovaginal candidiasis (P<.001). Patients using alternative therapies were also significantly more likely to have bacterial vaginosis diagnosed (34.3% users compared with 24.8% nonusers; P=.033). Similarly, CAM users were more likely to say that they had previously self-treated or been prescribed a medicine for vulvovaginal candidiasis (P=.02 and <.001, respectively). However, by the time they were seen at the Drexel Vaginitis Center, there was no significant difference in the prevalence of actually having vulvovaginal candidiasis or bacterial vaginosis between CAM users and nonusers.
A multivariable logistic regression (Table 5) was used to evaluate the adjusted odds of the factors affecting use of alternative therapies adjusting for significant factors at the 0.10 level from the univariable comparisons. Variables that were not significant in the final model were removed if the removal did not drastically affect the significance and effect of the other covariates. Women who had seen two or more doctors compared with one or less for their symptoms were more likely to use alternative methods (odds ratio [OR] 2.35, 95% confidence interval [CI] 1.41–3.93). Women who reported moderate (OR 2.01, 95% CI 1.14–3.55) and high (OR 2.92, 95% CI 1.32–6.45) interference to social life were more likely to use alternative therapies compared with women who reported that the conditions affected their social life some or none of the time. Because of the high correlation between the interference in social life and interference in work, only the former was added in the regression model. Hispanic or women of another race were more likely compared with African American women to use alternative methods (OR 10.59, 95% CI 1.88–59.63). White women also showed a higher odds of using CAM compared with African American women (OR 2.12, 95% CI 0.96–4.67), but it was not significant at the 0.05 level. Women who had graduate school education had higher odds (OR 1.94, 95% CI 0.90–4.19), although not significant at the 0.05 level, to use CAM compared with women with 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) were more likely to use alternative therapies compared with those who did not present these symptoms. Women who had a previous diagnosis of yeast infection were also more likely to use alternative therapies (OR 2.12, 95% CI 1.22–3.66).
The presence of CAM in the landscape of modern health care is well-established and growing. Despite this fact, it remains challenging to predict which patients will turn to alternative medicine and why. Several studies have sought to clarify the reasons that patients choose alternative therapies and demographic factors that are associated with CAM use. A 2004 study of patients with irritable bowel disease found that 60% of patients surveyed used CAM, and these therapies were more common in older married women.12 There was no statistically significant association found between CAM use and education, employment status, or several markers of disease severity. This is in contrast to other studies that have found an association between CAM use and higher income.1,13–15
Among the conditions identified in studies of CAM use, higher use was consistently associated with treatment of chronic diseases such as back pain, anxiety, and depression. There is essentially no mention of gynecologic symptoms in these large surveys, even among those that focus only on female patients. One study included the disease category of “menopause” and found that although few women reported using alternative therapies for menopausal symptoms (3%), women with menopausal symptoms were more likely to report use of CAM for other symptoms (OR 1.9).13 No survey studies that were identified, however, described the use of alternative remedies for chronic vaginitis, one of the most common reasons women seek gynecologic care.
In an initial attempt to characterize the chronic vaginitis population and their self-treatment habits, we reported in 1997 that 41.9% of surveyed women had used an alternative remedy for vaginitis symptoms in the preceding year.7 Thirteen years later, our current study found a much larger percentage of patients using CAM treatments for chronic vaginitis (64.9%). The demographics of the two study populations are similar, although a direct comparison of the two studies is not possible because of differences in the variables that were examined. It is interesting, however, to note that this growing trend in alternative therapy use in this population is consistent with national findings.
Many factors were identified as being significantly associated with CAM use, including patient age, race, level of perceived stress, previous diagnosis of candidiasis or bacterial vaginosis, greater interference with work and social life, discomfort in day-to-day activities, and number of doctors seen for evaluation of symptoms. Given the increased level of stress found in the women who used alternative therapies, it prompts the question of whether patients who turn to these methods have a greater sense of desperation compared with those who use conventional treatments alone. It is reasonable to suggest that patients with a chronic condition may turn to unproven alternative methods if they are dissatisfied with conventional therapies or if they are reaching a greater level of desperation in their search for symptomatic relief or cure. There are essentially no studies that assess the patient's feeling of desperation in dealing with a chronic condition and the subsequent use of alternative therapies except one. A study examining the narrative experience of parents with a child with Down syndrome and their use of CAM treatments examined the parents' possible sense of desperation in the face of their child's diagnosis.16 This study counters that desperation is not so much a motivation for using alternative therapies as the parents' desire to be active advocates for their children. It is unclear that this conclusion applies in the context of our patients choosing to use alternative therapies for themselves.
The primary limitation of our study was its dependence on written questionnaires, which led to incomplete data for some patients and potential recall bias for all. In addition, because we cannot be certain what conditions these patients had when their vaginal symptoms initially began, we are unable to comment on the efficacy of any of the CAM that patients used. Finally, although the current patient diagnoses were assigned by experienced providers with a special expertise in managing chronic vulvovaginal problems, it is possible that there was potential misdiagnosis in our patients at the time of evaluation. However, the use of stringent criteria for diagnosis should help to allay this latter concern. Despite these limitations, our study shows that CAM use is common in women with chronic vaginitis, particularly in those who are young, have more disruptive symptoms, and report greater stress. We feel that the results of our study lead to a better understanding of what factors motivate women with chronic vaginitis to use alternative treatments.
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© 2011 by The American College of Obstetricians and Gynecologists.