2. described more than a decade ago,7 there have been were compared using t tests, and nonparametric
no further attempts to evaluate current uses. Further- Wilcoxon rank-sum tests were used for nonnormal
more, little is understood about the factors that are data. Normality was tested using the Kolmogrov-
associated with their use. The purposes of this study Smirnov test. Categorical data were analyzed using 2
were to determine if OTC and alternative medicine tests. Fisher exact test was used when the predicted
use remains prevalent among women with chronic numbers in the cells were less than five. Variables
vaginitis and to evaluate which epidemiologic factors with missing data have a missing data category in the
are associated with greater use of these therapies. table; however, the missing data were not imputed
and were not used in the analysis. A multivariable
MATERIALS AND METHODS logistic regression was used to evaluate the adjusted
This prospective cohort study was approved by the odds of the demographic and clinical variables on the
Drexel University College of Medicine Institutional use of alterative medicines in the sample. List-wise
Review Board. Participants were recruited among deletion was used in the multivariable analysis, lead-
new patients presenting to the Drexel University ing to the model being performed for 404 cases.
Vaginitis Referral Center between November 2004 Statistical significance was set at the 0.05 level.
and February 2006 for the evaluation of chronic
vulvovaginal symptoms. Patient care was provided by
a board-certified gynecologist who had fellowship RESULTS
training in infectious disease and a women’s health A total of 481 patients enrolled in the study, and their
nurse practitioner with more than a decade of expe- demographics evaluated by CAM use are presented
rience in treating women with chronic vaginal symp- in Table 1. The overall population was divided into
toms. The center averages an estimated 3,500 return two subgroups: those who had used CAM (n 312,
and 500 new patient encounters each year. 64.9%) and those who had not (n 169, 35.1%). For
Informed consent was obtained from each patient the most part, the overall patient population consisted
before enrollment in the study. The patients were of white, well-educated, relatively wealthy women.
given a self-administered questionnaire that evaluated Most (64.4%) were married or living with a partner
a variety of factors, including demographic informa- and reported an annual income of $40,000 or more
tion, previous and current diagnoses, previous and (66%). Overall, 312 (64.9%) of women used at least
current medications, and medical and social history. one CAM.
In inquiring about past medications, the question- Compared with nonusers, patients using alterna-
naires asked about specific OTC and CAM treat- tive treatments tended to be younger than those who
ments and also asked open-ended questions to elicit did not (83.4% younger than 50 compared with
information about medications not included in the 73.1%; P .032), with the highest percentage of users
list. The questionnaire included the Center for Epide- in the 25- to 35-year-old age group (35.6%; n 112). A
miologic Studies Depression Scale,8 the Cohen Per- smaller proportion of CAM users were noted to be
ceived Stress Scale (maximum score 56),9 and the African American (11.9% compared with 21.3%;
John Henry scale (maximum score 60).10 As de- P .018). A greater proportion of CAM users (58.1%
scribed elsewhere,11 a standardized evaluation proto- compared with 53.2%) had college or graduate school
col was used to assign a diagnosis. In women with education, although this was not significant at the 0.05
multiple diagnoses, a primary diagnosis that clinicians level. There was no statistically significant difference
felt accounted for the bulk of the symptoms was between CAM users and nonusers in work status,
assigned. self-rated emotional health, history of a mental health
Patient information was analyzed to evaluate condition, Center for Epidemiologic Studies Depres-
relationships between patient characteristics and the sion Scale scores, or a history of medical, pain, or
OTC and alternative therapies used by the study autoimmune conditions. Users of alternative thera-
population. Different subgroups were then further pies reported a significantly higher level of perceived
analyzed in demographic and background informa- stress (mean 22.6, standard deviation 8.6) compared
tion, mental and physical health, duration and sever- with nonusers (mean 20.3, standard deviation 8.4;
ity of symptoms, and differing diagnoses to identify P .008, data not shown). When the perceived stress
potential differences between patients who used alter- variable was dichotomized at the 75th percentile, the P
native therapies and those who did not. value was significant only at the .10 level.
Data analysis was performed using Stata 10.1 Table 2 presents the various CAM that they used
(StataCorp LP, College Station, TX). Continuous data to self-treat their chronic vaginal symptoms. Among
VOL. 117, NO. 4, APRIL 2011 Nyirjesy et al Chronic Vaginitis 857
3. Table 1. Survey Population Demographics Table 2. Alternative Therapies Used by Survey
Population
CAM Not CAM
Used Used Therapy n (%)
(n 167, (n 312,
Characteristic 35.1%) 64.9%) P Yogurt 226 (46.9)
Acidophilus pills 162 (34.7)
Age (y) .032 Other health-food supplements 69 (14.4)
Younger than 25 20 (11.9) 45 (14.4) Low-carbohydrate diet 63 (13.1)
25–35 43 (25.8) 112 (35.9) Garlic or garlic supplements 41 (8.5)
35–50 59 (35.3) 100 (32.1) Low-oxalate diet 27 (5.6)
Older than 50 45 (26.9) 55 (17.6) Acupuncture 22 (4.6)
Missing 2 0 Glucosamine tablets 17 (3.5)
Race .018
White 126 (75.0) 256 (82.1)
African American 36 (21.3) 37 (11.9)
Hispanic or other 7 (4.1) 19 (6.09) or social life (57.9% compared with 40.2%; P .001),
Education .115 greater discomfort in day-to-day activities, and had
High school or less 37 (23.9) 45 (14.7)
Some college or 36 (23.6) 83 (27.0)
been seen by more doctors (median 2 compared with
technical school 1; P .001). When the array of symptoms experienced
College 46 (29.5) 101 (32.9) by patients was examined, there was no significant
Graduate school 37 (23.7) 78 (25.4) difference in the patients’ reported primary symptom
Missing 13 5 between the two groups. However, when asked to list
Marital status .121
Single 36 (22.6) 95 (30.9)
all the symptoms they found concerning, alternative
Divorced, widowed, 15 (9.43) 20 (6.5) therapy users exhibited higher levels of discharge
separated (55.8% compared with 39.1%; P .001), itching
Married 108 (67.9) 192 (62.5) (69.2% compared with 36.9%; P .001), and burning
Missing 10 5 (59.6% compared with 32.1%; P .001) compared
Depression scale .164
Not depressed 107 (70.4) 184 (61.3)
with nonusers.
Possibly depressed 23 (15.1) 59 (19.7) Current and past diagnoses were compared (Ta-
Probably depressed 22 (14.5) 57 (19) ble 4). Sixty-eight percent of CAM users and 32% of
Missing 17 12 nonusers reported a previous diagnosis of vulvovagi-
Cohen perceived stress nal candidiasis (P .001). Patients using alternative
th
More than 75 34 (22.4) 90 (29.9) .090
percentile
therapies were also significantly more likely to have
Missing 17 11 bacterial vaginosis diagnosed (34.3% users compared
Income .226 with 24.8% nonusers; P .033). Similarly, CAM users
Less than $25,000 27 (17.5) 32 (10.7) were more likely to say that they had previously
$25,000–$40,000 19 (12.3) 36 (12.0) self-treated or been prescribed a medicine for vulvo-
More than $40,000 95 (61.7) 204 (68.2)
Did not know 13 (8.4) 27 (9.0)
vaginal candidiasis (P .02 and .001, respectively).
Missing 15 13 However, by the time they were seen at the Drexel
Work .135 Vaginitis Center, there was no significant difference
Full-time 82 (52.6) 185 (61.3) in the prevalence of actually having vulvovaginal
Part-time 23 (14.7) 35 (11.6) candidiasis or bacterial vaginosis between CAM users
School or training 7 (4.5) 20 (6.6)
Retired, homemaker, 44 (28.2) 62 (20.5)
and nonusers.
unemployed A multivariable logistic regression (Table 5) was
Missing 13 10 used to evaluate the adjusted odds of the factors
CAM, complementary and alternative medicine. affecting use of alternative therapies adjusting for
Data are n (%) unless otherwise specified. significant factors at the 0.10 level from the univari-
able comparisons. Variables that were not significant
in the final model were removed if the removal did
CAM that were used, the most frequent were yogurt not drastically affect the significance and effect of the
(46.9%) and acidophilus pills (34.7%). other covariates. Women who had seen two or more
The duration, severity, and type of symptoms doctors compared with one or less for their symptoms
patients experienced were compared between the two were more likely to use alternative methods (odds
groups (Table 3). CAM users had higher interference ratio [OR] 2.35, 95% confidence interval [CI] 1.41–
in their work (59.1% compared with 40.6%; P .001) 3.93). Women who reported moderate (OR 2.01, 95%
858 Nyirjesy et al Chronic Vaginitis OBSTETRICS & GYNECOLOGY
4. Table 3. Duration, Type, and Severity of Table 4. Diagnosis in Alternative-Therapies
Symptoms in Alternative-Therapies Population
Population
CAM Not CAM
CAM Not CAM Used Used
Used Used (n 184, (n 312,
(n 184, (n 312, Characteristic 37.1%) 62.9%) P
Characteristic 37.1%) 62.9%) P
Diagnosis of or treatment 143 (90.5) 305 (98.4) .001
Interferes with social life .001 for yeast in past
None 95 (59.8) 130 (42.1) Missing 11 2
Moderate or some 43 (27.0) 109 (35.3) Treated yeast with over-the- 99 (69.2) 243 (79.7) .02
All or most 21 (13.2) 70 (22.7) counter medications
Missing 10 3 among cases
Interferes with work life .000 diagnosed
None 96 (60.4) 124 (40.9) Previous diagnosis
Slightly or moderately 46 (28.9) 113 (37.3) Unsure 9 (4.9) 19 (6.1) .58
Quite a bit or extremely 17 (10.7) 66 (21.8) Vulvodynia or vestibulitis 26 (14.1) 52 (16.7) .45
Missing 10 9 Yeast 61 (33.2) 216 (69.2) .001
Discomfort in day-to-day 37.4 28.8 45.8 28.4 .002 Bacterial vaginosis 42 (22.8) 107 (34.3) .007
activities Other 26 (15.9) 21 (8.4) .02
Discomfort with sex 65.5 31.7 59.7 31.9 .070 Drexel MD diagnosis
Duration of symptoms (y) .205 Bacterial vaginosis 17 (9.24) 19 (6.09) .19
1 or less 51 (35.7) 100 (33.4) Yeast 30 (16.3) 58 (18.6) .52
1–5 74 (51.8) 141 (47.2) Vestibulitis 20 (10.9) 38 (12.2) .66
More than 5 18 (12.6) 58 (19.4) Other 93 (76.9) 164 (81.6) .31
Missing 26 13 CAM, complementary and alternative medicine.
Number of doctors seen 1 (0–11) 2 (0–13) .001 Data are n (%) unless otherwise specified.
Number of times diagnosed 1 (0–15) 2 (0–75) .001
Primary symptom .120
Discharge 46 (29.9) 99 (33.6) American women (OR 2.12, 95% CI 0.96 – 4.67), but
Itching or irritation 50 (32.5) 114 (38.6)
Burning or pain with sex 48 (31.2) 67 (22.7)
it was not significant at the 0.05 level. Women who
Odor 5 (3.3) 12 (4.1) had graduate school education had higher odds (OR
Lumps 5 (3.3) 3 (1.0) 1.94, 95% CI 0.90 – 4.19), although not significant at
Missing 15 17 the 0.05 level, to use CAM compared with women
All symptoms with high school or less than high school education.
Discharge 72 (39.1) 174 (55.8) .001
Itching 68 (36.9) 216 (69.2) .001
Women who had itching (OR 2.43, 95% CI 1.38 –
Burning 59 (32.1) 186 (59.6) .001 4.32) and burning (OR 2.01, 95% CI 1.13–3.57) were
Pain 74 (40.2) 146 (46.8) .15 more likely to use alternative therapies compared
Odor 40 (21.7) 94 (30.1) .04 with those who did not present these symptoms.
Soreness 91 (49.5) 196 (62.8) .004 Women who had a previous diagnosis of yeast infec-
Lumps 15 (8.2) 26 (8.3) .94
tion were also more likely to use alternative therapies
CAM, complementary and alternative medicine. (OR 2.12, 95% CI 1.22–3.66).
Data are n (%), mean standard deviation, or median (range)
unless otherwise specified.
DISCUSSION
The presence of CAM in the landscape of modern
CI 1.14 –3.55) and high (OR 2.92, 95% CI 1.32– 6.45) health care is well-established and growing. Despite
interference to social life were more likely to use this fact, it remains challenging to predict which
alternative therapies compared with women who patients will turn to alternative medicine and why.
reported that the conditions affected their social life Several studies have sought to clarify the reasons that
some or none of the time. Because of the high patients choose alternative therapies and demo-
correlation between the interference in social life and graphic factors that are associated with CAM use. A
interference in work, only the former was added in 2004 study of patients with irritable bowel disease
the regression model. Hispanic or women of another found that 60% of patients surveyed used CAM, and
race were more likely compared with African Amer- these therapies were more common in older married
ican women to use alternative methods (OR 10.59, women.12 There was no statistically significant associ-
95% CI 1.88 –59.63). White women also showed a ation found between CAM use and education, em-
higher odds of using CAM compared with African ployment status, or several markers of disease sever-
VOL. 117, NO. 4, APRIL 2011 Nyirjesy et al Chronic Vaginitis 859
5. Table 5. Multiple Logistic Regression Model for (3%), women with menopausal symptoms were more
Alternative-Therapy Use (n 401) likely to report use of CAM for other symptoms (OR
Odds Ratio 1.9).13 No survey studies that were identified, how-
(95% Confidence ever, described the use of alternative remedies for
Variable Interval) chronic vaginitis, one of the most common reasons
women seek gynecologic care.
Number of doctors seen
None or 1 1 In an initial attempt to characterize the chronic
2 or more 2.35 (1.41, 3.93) vaginitis population and their self-treatment habits,
Age (y) we reported in 1997 that 41.9% of surveyed women
Younger than 25 1 had used an alternative remedy for vaginitis symp-
25–35 1.15 (0.46, 2.90)
toms in the preceding year.7 Thirteen years later, our
35–50 0.90 (0.34, 2.37)
Older than 50 1.09 (0.38, 3.18) current study found a much larger percentage of
Race patients using CAM treatments for chronic vaginitis
African American 1 (64.9%). The demographics of the two study popula-
White 2.12 (0.96, 4.68) tions are similar, although a direct comparison of the
Hispanic or other 10.60 (1.88, 59.64)
two studies is not possible because of differences in
Education
High school or less 1 the variables that were examined. It is interesting,
Some college or technical school 1.80 (0.82, 3.95) however, to note that this growing trend in alternative
College 1.24 (0.59, 2.65) therapy use in this population is consistent with
Graduate school 1.94 (0.90, 4.20) national findings.
Work
Many factors were identified as being signifi-
Full time 1
Part time 0.57 (0.25, 1.26) cantly associated with CAM use, including patient
In school or training 0.68 (0.24, 2.09) age, race, level of perceived stress, previous diagnosis
Retired or other 0.59 (0.31, 1.13) of candidiasis or bacterial vaginosis, greater interfer-
Interference with social life ence with work and social life, discomfort in day-to-
Some or none of the time 1
day activities, and number of doctors seen for evalu-
Moderately 2.01 (1.14, 3.55)
All or most of the time 2.92 (1.32, 6.45) ation of symptoms. Given the increased level of stress
Marital status found in the women who used alternative therapies, it
Married 1 prompts the question of whether patients who turn to
Divorced, widowed, separated 0.63 (0.23, 1.55) these methods have a greater sense of desperation
Single 1.27 (0.64, 2.52)
th compared with those who use conventional treat-
Stressed more than 75 percentile on 1.79 (1.00, 3.22)
Cohen perceived stress scale ments alone. It is reasonable to suggest that patients
Discharge 0.99 (0.54, 1.81) with a chronic condition may turn to unproven
Itching 2.45 (1.38, 4.28) alternative methods if they are dissatisfied with con-
Burning 2.01 (1.13, 3.57) ventional therapies or if they are reaching a greater
Pain 0.99 (0.57, 1.72)
level of desperation in their search for symptomatic
Odor 1.25 (0.65, 2.41)
Soreness 0.78 (0.43, 1.39) relief or cure. There are essentially no studies that
Previous bacterial vaginosis 1.02 (0.55, 1.89) assess the patient’s feeling of desperation in dealing
Previous yeast infection 2.12 (1.22, 3.66) 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
ity. This is in contrast to other studies that have found Down syndrome and their use of CAM treatments
an association between CAM use and higher in- examined the parents’ possible sense of desperation
come.1,13–15 in the face of their child’s diagnosis.16 This study
Among the conditions identified in studies of counters that desperation is not so much a motivation
CAM use, higher use was consistently associated with for using alternative therapies as the parents’ desire to
treatment of chronic diseases such as back pain, be active advocates for their children. It is unclear that
anxiety, and depression. There is essentially no men- this conclusion applies in the context of our patients
tion of gynecologic symptoms in these large surveys, choosing to use alternative therapies for themselves.
even among those that focus only on female patients. The primary limitation of our study was its de-
One study included the disease category of “meno- pendence on written questionnaires, which led to
pause” and found that although few women reported incomplete data for some patients and potential recall
using alternative therapies for menopausal symptoms bias for all. In addition, because we cannot be certain
860 Nyirjesy et al Chronic Vaginitis OBSTETRICS & GYNECOLOGY
6. what conditions these patients had when their vaginal 6. Van Kessel K, Assefi N, Marrazzo J, Ecker L. Common
symptoms initially began, we are unable to comment complementary and alternative therapies for yeast vaginitis
and bacterial vaginosis: a systematic review. Obstet Gynecol
on the efficacy of any of the CAM that patients used. Surv 2003;58:351– 8.
Finally, although the current patient diagnoses were 7. Nyirjesy P, Weitz MV, Grody MH, Lorber B. Over-the-
assigned by experienced providers with a special counter and alternative medicines in the treatment of chronic
expertise in managing chronic vulvovaginal prob- vaginal symptoms. Obstet Gynecol 1997;90:50 –3.
lems, it is possible that there was potential misdiag- 8. Weissman MM, Sholomskas D, Pottenger M, Prusoff BA,
nosis in our patients at the time of evaluation. How- Locke BZ. Assessing depressive symptoms in five psychiatric
populations: a validation study. Am J Epidemiol 1977;106:
ever, the use of stringent criteria for diagnosis should 203–14.
help to allay this latter concern. Despite these limita- 9. Cohen S, Kamarck T, Mermelstein R. A global measure of
tions, our study shows that CAM use is common in perceived stress. J Health Social Behav 1983;24:385–96.
women with chronic vaginitis, particularly in those 10. James SA, Hartnett SA, Kalsbeek WD. John Henryism and
who are young, have more disruptive symptoms, and blood pressure differences among black men. J Behav Med
report greater stress. We feel that the results of our 1983;6:259 –78.
study lead to a better understanding of what factors 11. Nyirjesy P, Peyton C, Weitz MV, Mathew L, Culhane JF.
Causes of chronic vaginitis: analysis of a prospective database
motivate women with chronic vaginitis to use alterna- of affected women. Obstet Gynecol 2006;108:1185–91.
tive treatments. 12. Burgmann T, Rawsthorne P, Bernstein CN. Predictors of
alternative and complementary medicine use in inflammatory
REFERENCES bowel disease: do measures of conventional health care utili-
zation relate to use? Am J Gastroenterol 2004;99:889 –93.
1. Barnes PM, Bloom B, Nahin RL. Complementary and alter-
native medicine use among adults and children: United States, 13. Brett KM, Keenan NK. Complementary and alternative med-
2007. Natl Health Stat Report, 2008;12:1–23. icine use among midlife women for reasons including meno-
2. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins pause in the United States: 2002. Menopause 2007;14:300 –7.
DR, Delbanco TL. Unconventional medicine in the United 14. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in
States. Prevalence, costs, and patterns of use. N Engl J Med, use of complementary and alternative medicine by US adults:
1993;328:246 –52. 1997–2002. Alt Ther Health Med 2005;11:42–9.
3. Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol. 15. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van
1991;165(4 Part 2):1168 –76. Rompay M, et al. Trends in alternative medicine use in the
4. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litakre United States, 1990 –1997: results of a follow-up national
MS. Over-the-counter antifungal drug misuse associated with survey. J Am Med Assoc 1998;280:1569 –75.
patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol 16. Prussing E, Sobo EJ, Walker E, Kurtin PS. Between “despera-
2002;99:419 –25. tion” and disability rights: a narrative analysis of complemen-
5. Marrazzo J. Vulvovaginal candidiasis. Br Med J 2003;326: tary/alternative medicine used by parents for children with
993– 4. Down syndrome. Social Sci Med 2005;60:587–98.
VOL. 117, NO. 4, APRIL 2011 Nyirjesy et al Chronic Vaginitis 861
