Yeast Infections: 

I see yeast infections every day in my office. Most women have at least some experience with this problem. Yeast is a huge problem on a global scale. I am going to spend quite a bit of time discussing it here because there are women who really suffer. Until the problem is resolved, it wrecks their life.

The symptoms could include vaginal or vulvar itching, some kind of discharge, maybe some swelling, sometimes there is burning to various degrees, and sometimes there is discomfort with sex. Sometimes the skin becomes so soft from inflammation that the skin actually cracks open from the minimal stress on it from daily activities, such as sitting or walking. When it gets that inflamed, the burning can become mind bending in severity. Usually, women won't let it get that bad. But sometimes, they have no choice and it becomes severe before they can do anything to fix it. Then, if the skin gets cracked, there can be bacterial infections on top of the yeast infections. Then, we need to get really serious about it and do everything we can, including admit patients to the hospital or even the ICU. I have seen all of this.

But sometimes, there are no symptoms at all. If a women has no symptoms but she clearly has a small or moderate amount of yeast in the vagina, we may choose to not call it an infection. We would only do this if there was no inflammation and no other problems.

Sometimes, the infection looks exactly like a jock itch that men get. Jock itch is a yeast infection that men get around their genitals, on their skin. Women can get the very same infection around their own genitals, even if it is not in the vagina, and the treatment may be the same as men. Jock itch is treated with jock itch spray that one can buy at the local pharmacy.  If a women has a jock itch, then vaginal treatments will be mostly unhelpful. If a woman tries a vaginal treatment, she will certainly wonder why the itch is not getting better. Technically, a jock itch in a women is not a vaginitis at all, but a vulvitis. Either way, many times they wind up in my office for consultation and advice and treatment options.

Interestingly, there are yeast infections that people get on other areas of the body. If a yeast germ somehow gets under the skin it will start growing in an expanding ring. The center might clear a bit. This ring is called, believe it or not, a "ringworm". It is most certainly not a worm. Ringworm is just like a jock itch, but in other areas of the body. In my practice I see ringworm type rings, centered on the vagina, sometimes going around the front all the way past the rectum. This infection is a yeast, not a worm. At this point, the infection could be called a "yeast infection", a "ringworm", or a "jock itch". All of them point to the same process. And the treatment is the same. It will be some oral meds, usually Diflucan, and some topical treatment including antifungals and antinflammatories.

Yeast organisms live in our environment. They are a natural and important part of our ecosystem. It is not possible to completely eliminate them from our environment. What we can do, though, is help our bodies defend ourselves from an attack by these germs. How do we defend ourselves?

First of all, stay healthy. A healthy body will have a healthy immune system, and that will help to fight off these germs. Healthy means eating a simple, safe, and balance diet, with minimal unnatural chemicals. In my mind, unnatural chemicals include preservatives, fake sugars, fake fats (like margarine or shortening), or overly processed carbohydrates. Too much sugar is bad for a human. What does it do? High blood sugars only feed the yeasts. Yeasts love the sugar and go nuts.  So diabetics, who have naturally high blood sugars, are much more likely to get yeast infections. But you don't have to be a diabetic to get a high blood sugar level if you eat a whole pecan pie, or have a 32 ounce soda. In my practice, we always see an abundance of yeast infections after Halloween and Easter. These two holidays usually include lots of candy in the revelry, and women get yeast infections quite a bit when they eat too much candy.

Try to lose weight. I know that sounds like empty advice when a person simply cannot lose weight no matter how they try. Believe me, I know. I am not skinny myself. But, I have to say it, because it might work.

Take your vitamins. In my opinion, a person cannot eat such a perfectly balanced diet that one would get all of the essential nutrients every single day. It is just not technically possible. My personal vitamin D level was very low, despite having evidence of too much sun on my skin. So, now I will have to supplement D for the rest of my life. I try to take my vitamins every day, but remembering it is a challenge. Try to leave the vitamins out, on the counter. They are much easier to remember that way.

Another important nutrient is Probiotics. These are the healthy bacteria that need to live in a human to assist them in living a normal life. There are thousands of bacteria that a human needs to live. This would include for instance staph epi (epidermidis),  and acidophilus, and thousands of other types. Our hospital now has a standing order to give our patients probiotics under certain circumstances. This would include antibiotic treatment. Bacterial antibiotic treatment is completely indiscriminate in its mission. It kills many of the good bacteria, while it is working to kill the bad ones. The end result of antibiotic treatment is, in may cases, not only a severe diarrhea, but an awful yeast infection. This is because the antibiotics have killed off the healthy bacteria that live in a normal vagina. Mainly, the healthy vaginal bacteria is acidophilus. A good acidiphilus will keep a vagina healthy by crowding out the yeasts, attacking the yeasts, creating the acid that keeps the vaginal pH very low, and actually making hydrogen peroxide. This kills all the invading germs. A woman that loses her vaginal acidophilus may be in for quite a lot of vaginal discomforts, until we can get her recolonized or at the very least replace the function of the acidophilus. If acidophilus just won't grow no matter what, then we can replace most of it's function with Boric Acid.  Boric Acid has just the right pH for a vagina, and can make a woman comfortable, but it is a long term treatment, and it is not a cure. Most of the "compounding" pharmacies around here are very skillful at making vaginal boric acid suppositories. They do it all the time for my patients. If a women is somewhat technical, she may be able to help herself with this. She has to remember to not take it orally. It will not help.

I have a microscope in my office and very frequently I will look at the vaginal fluids. It is easy to see acidophilus. They are non motile gently curved rods. If there are none, that is a problem. If the bacteria move, there is a problem. Of course, the yeasts are thick walled clumps, buds, or strands. they are easy to see. Bacteria stuck all over the epithelial cells are called "clue" cells. I don't have a clue why anyone named them that. But if they are there, that is a problem.  A women should have at least 80 percent of her epithelial cells clear of "clue" bacteria. Trichomonas are sometimes easy to see. That is a separate problem. They have a "flagella" that whips around really fast, and moves the Trich all over the place.

I also check vaginal pH. It should be very acidic, around 2-4. Any higher than that, and the abnormal uncomfortable germs can have a field day. We see elevated Ph's all the time. Sometimes, when nothing else works, it is time to get the Boric Acid to get the pH down.

A vagina should also be free of a certain kind of odor. For the sake of decency, I don't want to get too graphical with my metaphors. But, there are some odors that don't belong.

A pure yeast infection will mostly be free of bad odors. But, if there is a yeast odor, it may smell like beer, or fresh bread, from the obvious uses that humans have for the yeasts in our world.

There was an interesting study done about 10 years ago. What the investigators did was set up an exam room very near a pharmacies check out counter. When they saw a women buying a yeast treatment product, they asked the women if she wanted a professional exam. The exam was free, and she was told it was an investigational study. Most of the women agreed to have the exam. About a third of the women did not have a yeast infection at all. Many had a vaginitis, but of a different type such a bacterial, or trichomonas. Some had other very serious problems. There were even a few ectopic pregnancies, or appendicitis. These can be life threatening. There were some ovarian cysts, too. These are common, and only rarely a severe problem.

The bottom line is, if you are in any way unsure if it is a yeast infection, don't treat it without a professional opinion first. Or, if you do treat it with over the counter meds, and you don't get better in a day or two, you better come in for an exam. If it is the weekend, then strongly consider doing a pregnancy test. Even if you are menstruating right this very minute, it does not mean that you are not pregnant. Many pregnancies, and especially ectopics, have bleeding that is indistinguishable from a normal period. And ectopics are doubly risky if the mentruation is not like a typical period. And pregnancies can occur despite almost any kind of contraception. I like to tell my patients that even abstinence and virginity cannot totally prevent pregnancy. [I deleted a crummy Virgin Mary joke here, on the advice of someone I trust]. But, the reality is, plans for abstinence sometimes go awry.  And some women even forget that they have had intercourse. Or, are reluctant to admit it to themselves or their family. So a pregnancy test should be strongly considered if there is any doubt.

What do I do in my office? I keep a bottle of Fluconazole oral yeast treatment in my office. If it looks like a simple yeast infection I might just give her a single dose out of my office stock. I buy it in bulk and it is much cheaper. I give it away as a free sample. One dose can cure. The drug companies obviously don't give free samples of a drug that works in one dose, but there is no reason that I cannot give it away. If the yeast comes back, I will ask her to try some Monistat over the counter meds. If that is not enough. I will need to rule out other problems, like a lost acidophilus. I think the best monistat is the single day treatment. It has the most ingredients and it will likely work in one dose. There is no reason to use a vaginal cream for days on end. Women dislike the extended courses. It is uncomfortable and messy.

I also might ask their husbands to use some jock itch spray on their relevant body parts. This can help the woman if it is going back and forth. It might help the man a bit too. At least I don't think it would hurt him.

In the old days, the Gynecologists would paint the vagina with some "gentian blue". I have never done that. But I understand that it would really stain everything in sight a bright blue. I don't think women would like that.

This post is just the beginning of the microbiology of the vagina. What would you guys think of a series of photos of vaginal microscopy? Post below if anyone thinks it might be interesting, or if it is unneccessary and too icky.

More posts are coming. I have a ton of ideas. I have a number of requests for Toxemia, so that will come soon. 1 in 20 pregnant women get Toxemia. I will try to make some sense of it.

Thanks sincerely.

Please don't copy this article without my consent.

But links to here are appreciated.

Sincerely,

John Marcus MD FACOG
blog at doctorjohnmarcus.blogspot.com
89 North Maple Ave
Ridgewood NJ, 07450
Phone number 201-447-0077.

Ovarian Cancer Screening

You may notice that I haven't posted in awhile. I have certainly not stopped my blog, I have just been very busy. Even so, there are thousands of people who read this blog from all over the world. And it is still growing. Google is linking in from Ob/Gyn kinds of searches. Many of these blog posts have information that will not change much over time, so the search engines keep linking in here.

I have been a bit busy to blog much. I had to do my yearly boards exam. That is about 35 hours of open book testing, done in "free time". So it always takes me a long time. I score very well on these tests, but I am very careful to read the questions and the reading material. Also, we had summer vacations to deal with. My covering doctor, Fred Rezvani, took some time off, and that leaves me with covering his patients as well. I like doing it, but it does take up a lot of time.

Today's blog post is about Ovarian Cancer Screening. This is a contentious subject. It is certainly not a hopeless subject, but we can certainly do a lot better than random screenings.

Occasionally I will get a request from a patient to do some kind of medically unnecessary testing. This might include some unnecessary testing for ovarian cancer. Similarly, sometimes a patient or her family will want to have an obstetrical sonogram that is not on the list of traditionally accepted indications. I have seen instances where the patient's family is in from overseas and they have not seen the baby yet.  They would like to see the baby before they leave to go back home.  And in a situation like that I will sometimes do a so-called unofficial sonogram and show the baby to the family. Also, there are situations where the patient does not feel the baby moving.  It may be too early in the pregnancy to expect such fetal movements.  But even so, the stress level can get so high, a quick peek at the baby with the sonogram is valuable to convince the woman that she and her baby are fine.  The stress reduction is so gigantic, that it is a very worth while sonogram to do.  Sometimes, if the sonogram is not available, just checking the fetal heartbeat with the Doppler is rewarding.

Ovarian cancer screening, however, is very murky.  The scientific evidence at this time seems to be that the usual screening methods do more harm than good. There is a recurrent ovarian cancer e-mail that goes around on the Internet.  It is extremely common.  This email advises woman to take control of the own destiny and demand a sonogram and a CA 125 test. If the patient asks me about this situation, this is what I usually try to do:

I will not utterly deny her the testing.  If she is completely convinced she needs the test, and I don't do it, I will have likely lost this patient for good.  This means that I will be unable to give her good medical care in the future, and she may not get any good medical care at all. I think this scenario is even riskier then doing the scientifically unproven ovarian cancer screening.

But, I will explain to the patient that the scientific evidence is at best murky, and that at worse shows actual harm to the patient.

A smart person might legitimately ask "how can a simple blood test and a simple sonogram harm a person?".  The answer lies in the fact that no lives are saved by this set of testing.  Sure, we find many ovarian cysts, many ovarian tumors, and even a few cancers.  But the comparison group between screened and the non screened   individuals shows no difference or worse for the screened group. This was originally proven by the Gilda Radner study. Gilda was a famous and wonderful comedian who died when she was young. She died of ovarian cancer.  Her husband, the famous Gene Wilder (the first Willy Wonka), sponsored a medical study to try to help save women from ovarian cancer.  This study, and several since, showed harm to the screening group, or at least no benefit.  I am told that the Gene Wilder study cost $7 million dollars.  And it was a good study.

Why is the screened group harmed?  Because, among other things, they are exposed to a lot of unnecessary surgery.  This surgery has a lot of risks.  Surgery, if unnecessary, still leads to the risks of infections, bleeding, scarring, and damage to adjacent organs.  These risks are high enough to lead to more harm to the screened group then to the non-screened group.  But the situation is worse than that. The women who get the screening tests done become very reluctant to really come in when it actually becomes necessary.

What I mean is, that a patient who has an ovarian sonogram, will have a feeling that she is so healthy that she will refuse to come for medical care even when it is necessary, when her ovaries are painful or bloated. When a woman has painful or bloated ovaries,she must come in for an evaluation.  But, not for a screening evaluation, it is now a medically necessary diagnostic intervention. The scientific analysis that these tests are valuable is indisputable. The problem with the screened group of women, is that they will not come back for these tests.  I have had women say, "but I just had a sonogram and it was normal!"  I will tell them, that I don't care if the sonogram was done last month, she needs another one. People can certainly get a clinically evident ovarian tumor in the space of the single day.  It is a mathematical and  medical certainty for any given person who has a tumor, that it was undetectable prior to becoming detectable, and since we have no control over when that transition to detectability occurs, we must start a new evaluation every time there are new symptoms of problems. The woman who have been screened for ovarian cancer will sometimes not come back for years despite the new onset of problems. they seem to forget that every cancer is undetectable before it is detectable. When a woman says to me "but I just had it done...", I will look in the chart and sometimes see that it was years ago. That doesn't surprise me at all, because I certainly cannot remember the last time I had an EKG, or anything else. I feel like my colonoscopy was 2 days ago, but it was years ago, and I certainly cannot remember which year. Who wants to remember those things? That's what medical records are for.

Of course there are grey areas in between non detectable and detectable tumors, and there is a fuzzy kind of logic in between the two situations, but that doesn't change the fact that all tumors are not detected before they are in fact detected. And we don't know when that transition happens.

So, we have a situation where we have screening tests done, but in general do more harm than good. But Diagnostic Testing does more good than harm. All women should strive for diagnostic testing instead of screening testing.

But, women should think about this: How often does a women get a screening test? Since there is no science that screening helps women, we have no idea how often to do it. This is like the mathematical equivalent of dividing by zero, the result is not defined. So, we can guess that maybe yearly screens are a good idea. Or, if a woman has a lot of time and money, she could get screened twice a year. There is no good answer.

But, Diagnostic testing is different. Diagnostic testing for ovarian pain and bloating can be done more often than once a year, if it is necessary.   Diagnostic testing has been indisputably proven to help women better than screening.  And, it can be done more frequently, if and when it is necessary.

What happens when we follow this diagnostic protocol? It seems to me that something magical happens. Women themselves become an integral part of the chain of events that are necessary to save their lives from cancer. Think of how empowering that is for women. Think of one woman, who says, "I demand a sonogram and CA125 blood test, even though I feel good". The science shows that that woman is harming herself, under the misguiding thought that these tests might help save her. And, she may wind up paying for these harmful procedures, since they are not medically necessary. That is quite expensive. But, another women, a bit smarter maybe, will get yearly checkups of course, but will reserve her ovarian cancer testing for the one unfortunate day when she is bloated, or in pain. Her diagnosis may be dramatically sooner in the disease process than a previously screened women. So, the second women is empowered to become part of the system. She is, herself, by force of will alone, becoming a link in the ever important chain of human events that create an early detection system for ovarian cancer. This is so much better than a dumb and blind stab in the dark at a random screening for ovarian cancer.

Despite these proven the advantages of diagnostic testing done when indicated, some women still want to be screened.  If I explain the harm proven in the above studies, and the patient still wants screening, I will do it for them.  But I will emphasize for them, that they still need to come back if they ever get ovarian pain and bloating.

There are physicians who dispute the above science.  They will screen either every woman who comes through the door, or every woman who asks. These physicians will of course be doing a lot of surgery on healthy women.  These surgeries can become the most lucrative part of their practice. They may make a very good living by doing this style of practice.  And they are making a lot of women very happy by telling them they don't have cancer in the postoperative recovery room. They will say it with a big dramatic sigh of relief.

Don't get me wrong, I don't think that ovarian cancer screening is impossible.  I just don't think it is ready for prime time. There is lots of cancer screening that has been proven beneficial.  The Pap smear is great. The Pap smear is so great that we are probably overusing it. Colonoscopies most definitely save lives. I have had mine done. One day, we will get a protocol that works. It might involve proteomics, or it might involve MRI's.

Like I said before, when woman understands the above, and she still wants her ovarian cancer screening, I will do it. You would all be surprised, however, how many women believe the above scientific analysis.  Most women agree to follow the scientific protocols.  Most women agree to hurry back to the office if her ovaries become sore or bloated.  Then I can do the indicated testing, and maybe help save her life.  This is more successful than any screening protocol yet devised. And maybe I will get to see her more often than once a year.  This is fine by me.  I know that, without a doubt, I am providing better care by doing this.

Thank you sincerely.

I hope I have explained the above two groups of women adequately. Those two groups being the unscreened women and the screened women. And you may notice that this post is nonscientific. It is just my thoughts. There are no peer reviewed references. If I did that, this blog would be very different.

Please feel free to forward this note on to other people. Maybe we can get it to go viral. Just be sure to include the following lines:

John Marcus MD Obstetrician and Gynecologist.
Ridgewood, NJ, USA
Phone number 201-447-0077
Member of The Lifeline Group at www.lma-llc.com
Blog at doctorjohnmarcus.blogspot.com