Introduction

The symptoms of vulvovaginal candidiasis(VVC), which would be brought on by an overgrowth of Candida species in the vagina, include itching, irritation, and curd-like vaginal discharge¹. In healthy, asymptomatic women, the lower tract flora comprises 20–50% Candida albicans. Vulvovaginal candidiasis (VVC) is characterized as a disease with inflammation-related symptoms and signs and a variety of causes ². 75% of women encounter at least one episode of VVC during their lifetime. Though it’s reported about   5% of women experience vulvovaginal candidiasis ². The main symptoms are itchiness and burning, along with discomfort, irritation, dyspareunia, & dysuria. Other common symptoms include fissures, vulval and vaginal erythema, increased vaginal discharge, and edema ². Vulvovaginal candidiasis is usually classified as either sporadic or recurrent on the basis of episodic frequency. It is clinically imperative to distinguish between sporadic and recurrent infections not only to understand the pathogenesis of each but also to formulate specific diseasemanagement strategies²¹.The major risk factors for developing VVC are like oral contraceptive use, hormonal replacement therapy. It creates an estrogen-rich condition , which stimulates fungal growth and reproduction as well as vaginal colonization ³. So far, vigorous mucosal inflammation that is primarily brought on by fungal overgrowth in the vagina and followed by epithelial invasion and the synthesis of virulence effectors can result in symptomatic infection²⁴.Other risk factors, like as genetic factors that influence the host’s susceptibility to infection, inflammatory response development, vaginal microbiota dysbiosis, sexual activity, personal hygiene, and dressing pattern, as well as an illness like diabetes mellitus, can contribute to the development of VVC in addition to an environment that is high in estrogen ³. The vaginal microbiome (VMB), which is influenced by both internal and external variables like menstruation, intestinal microbiota (near the rectum), and personal contact, is crucial for preventing the colonization of infections. The diseased condition like Diabetes mellitus(DM) which creates favourable environment for candida overgrowth, the presence of sugar also stimulate the Vulvovaginal candidiasis. The main reasons for this colonization seem to be altered functions of the immune system in diabetic patients with poor glycemic control or a direct effect of elevated blood glucose levels, creating specific conditions for intensive fungal colonization¹⁷.In order to reduce the risk of VVC; proper vaginal hygiene should be maintained. Avoid unnecessary usage of antibiotics, oral contraceptives etc. Use loose fitting undergarments; to reduce the chance of friction and moisture retain in vaginal area. Maintain a proper healthy diet to improve the vaginal health. Vagina’s acidity, bringing it down to pH 5.0-6.5, allowing pathogenic organisms like Candida to flourish.Age, menstrual cycle phase, sexual activity, choice of contraception, pregnancy, the presence of necrotic tissue or foreign substances, and the use of hygiene products or antibiotics can all cause a rise in vaginal Ph²⁷.

Materials and Method

Study design: Prospective study

Study site: Paalana Institute of Medical Sciences Palakkad, a multi super- specialty hospital that is well equipped and has a capacity of more than 250 beds.

Sample size: n= 90

Study period: July 2022 to December 2022 (6 months).

The study was approved by Institutional Ethics Committee GCP/IEC/112C/2022 dated 05-07-2022.

Inclusion Criteria

Female patients in age 18-65 years diagnosed with VVC and also willing to give consent for the study. 

Exclusion Criteria

Patients with STD, pelvic inflammatory disease, fibroids, endometriosis, serious health problems like liver failure, renal failure, and heart disease, and Vulvar dermatoses like lichen sclerosis.

Data collection

The study was explained to patients and written informed consent was taken from patients. The study population is then categorized into women of reproductive age, pregnancy, and post-menopausal age. Investigation of Risk Factors is done by using the data collection form, it includes the general required information such as age, body weight, BMI, occupation, and educational level; daily living habits such as the frequency of drinking sweet drinks and eating sweet foods, the frequency of exercise, and daily emotional state; hygienic habits such as menstrual care, underwear material and the previous history of any contraceptive methods, reproductive histories such as marriage state, history of vaginitis, and history of abortion; sexual behaviors, etc. This study aims to estimate the risk factors for developing VVC among women at reproductive age, pregnancy, and post-menopausal age. 

Statistical Analysis

The collected cases were entered in MS Excel 2007 for calculating the percentage of various parameters. Descriptive statistics like frequency and percentage, standard deviation were used to describe the demographic characteristics and determinants of VVC. 

Result:

A total of 90 patients were included in this study. Among the collected data, VVC was more prevalent among women in the reproductive age group 18-35 (40%), in the pregnancy age group 20-29(13.3%), and in post-menopausal age group 60-65 (12.2%) (Table -1).VVC is more common among married women [88 patients] (97%) and only 3% [2 patients] having VVC among un-married women (Figure-1).Prevalence of VVC is higher in women’s with BMI ranging between 25-29.9 (54.4%),which indicates overweight is the main reason for developing VVC; BMI range <18.5(2.2%), BMI range between 18.5- 24.9 (54.4%), BMI range >30 (7.8%) (Table-2).

Among the study population (n=90), 86.7% of the patients have lack of regular exercise and 13.3% of the patient with regular exercise (Figure-2).

Past medical history like Diabetes mellitus (27.7%), hypothyroidism (27.7%), Urinary tract infection (20%), obesity (14.5%), PCOD (7.7%), anemia (3.4%) Others (27.8%) and past medication history like administration of antibiotics (23.3%), steroids & oral contraceptives (1.1%) were the major risk factors for VVC (Table -3)

Table 1: Prevalence Distribution of Women Based on Age Category (n=90).

 Table 2: Distribution Based On Bmi

 Table 3: Distribution Based on Past Medical and Medication History.

 Distribution Based on Marital Status

Figure 1: Distribution Based On Marital Status. Click here to view figure

Distribution Based on Daily Exercise

Figure 2: Distribution Based On Daily Exercise. Click here to view figure

Discussion

The symptoms of vulvovaginal candidiasis, which is brought by an overgrowth of Candida species in the vagina, include itching, erythema, and curd-like vaginal discharge¹. In healthful, asymptomatic women, the lower tract microbiota comprises 20–50% Candida albicans. Under this study, VVC is more prevalent in 40% of women between the age of 18 and 35 who are sexually active (Table: 1). Women under 40 had twice as high a risk of getting VVC as those over 40, according to previous research⁵. The Studies have reported the prevalence of VVC as 25%, 24%, and 18.5% ^{7, 8, & 9} (2015). The age group of 26 to 30 years had the greatest percentage of VVC (39.08%), followed by the age group of 31 years, based on a study by Dr. Meena Salvi et al (2019).The majority of women were sexually active during the reproductive years, and their bodies also produced more estrogen at this time. Women in this age group tend to have multiple children and frequently utilize contraception, which is beneficial for candidiasis ¹⁰. Young women may be more susceptible to negative influences including unsafe sexual practices, which may account for the higher prevalence of VVC in this population ⁵. Additionally, during this period of life, women experience physiological and tissue changes brought on by reproductive hormones that make them more vulnerable to Candida infection ⁵. The results indicate that married women (96.7%) had a higher incidence of candidiasis than single women (Figure: 1). The prevalence of candidiasis is estimated to be 18 (28% of married women) and 10 (20%) in Iyevhobu Kenneth oshiokhayamhe et al studies¹¹. Differences in the vaginal environment and sexual practices cause VVC in married women. This study found that VVC is more common in women with higher BMI levels (overweight). Prevalence of VVC is higher in women’s with BMI ranging between 25-29.9 (54.4%),which indicates overweight is the main reason for developing VVC (Table:2). Obesity is a low-grade inflammatory condition, and adipose tissue is an immunological organ that is active and produces higher tumor necrosis factor (TNF), interleukin (IL)-1, and IL-6. Obesity is associated with an increase in infection susceptibility ¹². Gary Ventolini et al., demonstrated in their research that obesity can be an independent risk factor for VVC in women of reproductive age through the mechanism of altered vaginal immunity ¹². Obese people may retain moisture in their body folds, which can encourage the development of candida overgrowth. 86.7% of the 90 participants in this research don’t exercise regularly. Previous research has focused on the effects of regular exercise, a sedentary lifestyle, and regular emotional states. In the end, regular exercise and positive feelings protected the VVC ⁵. Regular exercise helps keep a healthy weight while enhancing immunity to several diseases. When it pertains to their eating habits, 96.7% of people follow a mixed diet, while 11.2% frequently consume sweet foods. A body with more sugar promotes a glycogen environment that is suitable for Candida species, and regular intake of sweet foods boosts the chance that diabetes will develop. This may be a factor as far as how Candida can adhere to vaginal epithelial cells and continue to develop as a result of the enhanced glucose concentrations in vaginal secretions ⁵.Several risk factors contribute to vulvovaginal candidiasis. The following physiologic alterations that take place during pregnancy increase the risk of VVC: decreased cellular immunity, raised hormone levels, reduced vaginal pH, and elevated vaginal glycogen content ¹³. A few other personal hygiene, dressing, and sexual practices are also risk factors, also with hyperestrogenism, hormonal imbalance, immunological suppression during disease or psycho-emotional stress, hyperglycemia, vaginal dysbacteriosis, IUDs, spermicidal, condoms, hyperglycemia¹⁴. One of the major reasons for VVC, among many others, is hormonal imbalance. It was once hypothesized that the hormones estrogen and progesterone might be used in contraceptives to increase vaginal glycogen and make them more susceptible to the action of lactobacilli. Most experts agree that lactobacilli have a role in the conversion of glycogen into lactic, which reduces the pH of the vagina. The lower pH inhibits the activity of the bacterial biota, which encourages the development of yeast, particularly Candida species ¹⁵.Pregnancy frequently results in vaginal candidiasis, which is caused by a change in pH and sugar levels. Increases in estrogen in pregnancy lead the vagina to generate more glycogen, which has a direct impact on yeast cells by increasing their multiplication and causing them to adhere to the vaginal walls ¹⁶. As the high estrogen levels increase the glycogen content in vaginal secretion, the incidence of VVC increases without any negative consequences during the pregnancy ^31. Vulvo   vaginal   candidiasis   is   an   important   cause   of morbidity inpregnancy  which can result in  miscarriages, candida  chorioamnionitis,  subsequent  preterm  delivery and emotional stress³⁰.The hormonal balance in the vaginal microbiota is changed as a result of previous medical history, including the use of contraception tablets or any other method of contraception. The next major risk factor is the overuse of antibiotics. In this research, 22.3% of the participants had previously taken antibiotics. A barrier against infection, colonization resistance, and Candida germination are provided by the usual protective vaginal bacterial flora⁶. Wearing tight undergarments and the type of underwear used, in addition to these and other factors, enhance VVC. Synthetic underwear does seem to cause increased friction and maceration, which increases the local acidity and encourages the growth of fungi. Undergarments made from cotton and clothes with proper ventilation may help prevent infection ¹⁷. This study examined the consequences of past medical conditions such as obesity, PCOD, hypothyroidism, urinary tract infections, and diabetes mellitus. A history of DM (about 27.7%), hypothyroidism (about 24.5%), UTI (about 20%), and obesity (about 14.4%) were among the participants. A lot of earlier studies have already examined the connection between DM and VVC. Hyperglycemia is the major factor enhancing diabetic individuals’ susceptibility to vulvovaginal candidiasis. Yeast grows and adheres to vaginal tissues as blood sugar levels rise. Vascular epithelial cells adhere to Candida albicans more frequently in people with diabetes ¹⁸. Sugar in the urine accelerates the spread of the infection. Hypothyroid patients are less likely to build immunity and have lower body temperature;it favors candida over growth. The assessment of local safety and allergic reactions in the vaginal environment has been a key component of certain research on the association between a patient’s immunity and the incidence of VVC ¹⁹.VVC development seems to be more likely when pantyliners and material underwear are synthetic. Pantyliners may retain heat and moisture, which could promote the growth of VVC or microorganisms²⁰. For epidemiologic characterization and effective infection therapy, the etiological agent must be correctly identified. Therefore, more precise techniques are needed to choose a therapeutic course of action and to reduce patient risks, such as molecular techniques and antifungal susceptibility tests for Candida spp²⁸.

Conclusion

The study concluded about the possible risk factors to cause Vulvovaginal candidiasis (VVC). VVC was more prevalent in women in the reproductive age range due to their hormonal influences, sexual behavior, personal hygiene, and other variables. Sexual practices and personal hygiene have a significant impact on vaginal infection. Obesity; lack of regular exercise and past medication histories, such as the use of antibiotics, and past medical history, such as diabetes mellitus (DM), were significant reasons to cause VVC. 

Acknowledgement

I would like to express our sincere thanks to all the medical and non-medical staffs and patients of Paalana Institute of Medical Sciences; Palakkad, Kerala

Conflicts of Interest:

No conflicts of interests declared by the authors

Funding Sources

The study was approved by Institutional Ethics Committee GCP/IEC/112C/2022 dated 05-07-2022.

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