Vaginitis in the adolescent patient.

For any clinician involved in the health care of women, vaginitis remains an unavoidable problem. Vaginitis accounts for an estimated 10 million office visits each year, and it remains the most common reason for patient visits to obstetrician-gynecologists. 20 With the availability of over-the-counter antifungal therapies, these products now rank among the top 10 best-selling over-the-counter products in the United States, with approximately $160 million in sales. In the adolescent population, accurate numbers with regard to use of products for vaginal symptoms are not available, but some numbers suggest that such use is common. For example, in a college student population, 61% reported having experienced a vaginal yeast infection; 70% of these young women had relied on self-diagnosis and self-treatment for these yeast infections. 26 Despite extensive self-diagnosis and self-treatment for vaginal symptoms in all age groups, important questions persist about the accuracy of such an approach. The package insert for over-the-counter antifungal preparations recommends their use only in women who have been given a prior diagnosis of a yeast infection. Initial data suggested that, in women with a prior diagnosis of vulvovaginal candidiasis (VVC), as many as 82% could accurately diagnose themselves based on symptoms alone 8 ; however, this figure may represent an overestimate because patients in this study had been screened by telephone initially and were evaluated only if they had symptoms that sounded similar to VVC. In a questionnaire study of 634 women, Ferris and colleagues 11 found that only 11% of women could accurately recognize the classic symptoms for yeast infections; in women with a prior diagnosis of VVC, 34.5% rendered a correct diagnosis of VVC. Meanwhile, only 3% could identify bacterial vaginosis, vaginal trichomoniasis, or pelvic inflammatory disease (PID). If studies show such a poor ability to recognize and assign proper diagnoses to different vaginal infections even on theoretic grounds, it is doubtful that women, particularly adolescents, can accurately diagnose themselves. Finally, telephone diagnosis is probably no better than self-diagnosis. In a study of women who were assigned a nurse-administered telephone triage protocol diagnosis and then were physically evaluated, poor agreement was noted between the over-the-phone and in-office diagnoses, with κ coefficient scores that were marginally better than random chance alone. 1 Given the preceding information, the best chance at an accurate diagnosis seems to remain in the hands of clinicians. Although vaginitis is frequently trivialized by the medical community, it should be emphasized that women who present with vaginal symptoms deserve a thorough and complete evaluation. Some causes of vaginitis, such as trichomoniasis, are sexually transmitted infections, and these patients need further counseling about the prevention of sexually transmitted diseases (STDs) and the treatment of their partners. Other infections, such as bacterial vaginosis, are risk factors for more severe processes, such as PID. Even a local problem, such as VVC, may have important morbidities in terms of discomfort and pain, days lost from school or work, and sexual functioning and self-image, particularly if it becomes chronic and is not treated effectively. The vagina is one of the few sites of the body that, when infected, can be easily examined and accessed for diagnostic tests. With a standardized approach to the evaluation of vaginal symptoms, a cause can be identified in most cases, and the plethora of available treatment regimens allows selection of an appropriate agent that yields satisfactory results in most women.