Introduction

Vulvovaginal candidiasis(VVC) is frequently brought on by Candida albicans. About 40% and 75% of women have vulvovaginal candidiasis signs^{1, 2}. Vulvovaginal candidiasis is a pervasive, irritating, and frequently recurrent infection that has been related to diabetes, pregnancy, and broad-spectrum antibiotic treatment. Inflammation, itching, abnormal vaginal discharge, painful urination, and sexual intercourse are the main signs of VVC. Such symptoms result in varying, but frequently quite intense, pain¹⁶. VVC is characterized by vaginal discharge; vulvar itching/irritation, and malodor. Candida albicans are part of the lower tract flora in 20-50% of healthy asymptomatic women. Vulvovaginal candidiasis is caused by the overgrowth of Candida species in the vagina and is characterized by itching, erythema and curd like vaginal discharge. The changes in the composition and function of the vaginal microbiota may expose females to Candida infection²⁵.Although there is evidence that condition such as a high-sugar diet, the usage of tampons or perfumed toilet paper, or wearing tight clothing, may enhance the chance of vulvovaginal candidiasis¹.

These infections create a risk to the well-being of the women and have a deleterious effect on their quality of life (QoL). Vaginal infections are frequently avoided because of their aspect ³. A yeast or fungus termed Candida overgrows in the vagina, potentially causing an infection known as Vulvo-vaginal candidiasis. This yeast, in addition to several many other organisms, is typically found within the mouth, gut, and vagina. Yeast can overgrow if the organisms’ delicate balance is upset ³. The WHO defines quality of life (QoL) is defined by the World Health Organization as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. The phrase “health-related quality of life” refers to the distinct effects of a medical condition, medical treatment, or health care policy on an individual’s level of well-being and was first created and operationalized with adult illness populations ⁴. Recent research has shown that these fungi have a significant detrimental effect on women’s quality of life, highlighting the significance of providing the patient with VVC with the best available treatment and care ⁵. Social implications and an extremely distressing decline in the quality of life, such as sexual function and relationships ⁶. The symptoms of this infection and its treatment have a significant impact on the physical, mental, and sexual well-being of many women¹⁷. Consequently, it appears that sticking to a nutritious diet and practising hygiene can help to prevent candidiasis infection¹⁸. Impact various to a person’s overall way of life and behavioral patterns, including the way they eat, their eating habits, how they use their free time, whether they smoke, how much they exercise, and how they use healthcare services¹⁹. The results of these symptoms of VVC have a terrible effect on that woman’s self-esteem as she feels that she is undesirable as a woman and there are difficulties in intimate relations when it is associated with their problems with the Candida yeast infection. The women felt particularly vulnerable regarding their conditions in large part because of the bad odor that they carried around with them as a result of their infections. They could feel themselves closing off to social situations that involved being in close proximity to others. The odor made them very self-conscious at work, in social situations and in their intimate lives²¹. This study’s aim is to evaluate the severity of symptoms, quality of life, and emotional aspects in patients with VVC by using VSQ and VDQoL questionnaire. 

Materials and Method

Study design: prospective interventional study

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

n = Sample size

Z = Statistic corresponding to the level of confidence

P = Expected prevalence

d = Precision (corresponding to effect size)

Study period: July 2022 to January 2023 (7 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.

A pre-designed patient data collection form is used to collect the required information, regarding the patient’s demographic details, past medical and medication history, detailed family history, reproductive history, signs and symptoms, laboratory investigations, and treatment chart. After the interaction with patients; their emotional aspects like anxiety and stress due to this infection were also noted in the data collection form. Also obtained informations related to their daily activities, sexual satisfaction,emotional state  by using VSQ and VDQoL questionnaires. 

Study tools

Vulvovaginal symptom questionnaire (VSQ)

VVC severity is analyzed by using a VSQ questionnaire. Scale-based vulvovaginal symptom questionnaire (VSQ) to determine sexual impact and symptoms of skin disease The Vulvovaginal Symptom Questionnaire (VSQ), which is scored as zero for “YES” answers and one for “NO” answers, defines the severity of the patient’s symptoms⁷. Women who answered “No” to all of the first seven questions were considered to be without vulvovaginal symptoms.  After these subscales are completed, the next question, question 17, asks women; if they are currently sexually active with a partner.  In sexually active women (women who report “Yes” to question 17), the VSQ is a 21-item instrument and scores range from 0 to 20.  Increased scores indicating increased vulvovaginal symptom bother.

Vulvar disease quality of life index (VDQoL)

The VDQoL questionnaire was used to evaluate the baseline quality of life⁸. The goal of this VDQoL is to determine the extent to which the infection has an impact on the sexual life, physical activity, feelings, and worries about future health. Very much = 3, a lot = 2, a little = 1, and not at all = 0 are the VDQoL scores ^{9, 10}. The minimum total score is 0/45, and the maximum is 45/ 45, interpreted as follows:  The VQLI was divided into four domains: Symptoms (Questions 1–2), Anxiety (Questions 3–5, 14) Activities of Daily Living (ADLs) (Questions 6–10, 15) and Sexuality (Questions 11–13).

The same questionnaire will be administered again during the review period (After completing the course of treatment). The change in the quality of life from baseline will be noted. This study aims to estimate the severity of symptoms among patients with VVC and determination of (QoL) quality of life in the study population between pre-treatment and post-treatment after a patient counseling (baseline and follow-up). 

Statistical Analysis

The collected cases were entered in MS Excel 2007 for calculating the percentage of various parameters. Data were presented using descriptive statistics in the form of a percentage, and standard deviation. By using GraphPad Prism software, an Unpaired Student t-test was carried out to determine the difference between the pre-treatment and post-treatment

Result

A total of 130 cases were included in this study. Socio demographic details were presented in (Table-1). Among the collected cases, VVC was more prevalent among women in the reproductive age group [18-35] (37.6%), in the pregnancy group [20-29](12.3%), and in the post-menopausal age group [60-65 ](15%). Based on the educational status about 55.5% of the patients having high school education, followed by 42.3% of the patients were graduates & 2.2% of the patients were having primary school education. Among the study population (n=130), 81.2% of the patients were unemployed and 18.9% of the patients were employed. By obtaining data regarding the emotional aspects of women with VVC, about (96.1 %) have stress and anxiety (Figure-1). To determine the severity of symptoms in patients with VVC, Vulvovaginal symptom questionnaire (VSQ) were used. Before the treatment, 26.1% cases had  VVC severity scores(>10), and 74.6% had severity score(<10). After the treatment, 7.6% had a severity score(>10) (p-value 0.98), and 92.3% had a severity score(<10) (p<0.0001).On comparing the symptom severity (Score ≤10) between pre-treatment & post-treatment (p<0.0001), statistically significant (Table-2).

Among the total of 130 participants, Quality of life(QoL) is determined by using the Vulvar disease quality of life index questionnaire (VDQoL). Before the treatment; 1.1% had a Nil effect, (60%) had a Mild effect, Moderate (37.6%), and Severe (2.3%). After the course of treatment, their QoL is determined by administering the same questionnaire to the patients. 2.2% having a Nil effect, 90.7% having a Mild effect, and Moderate (7.69%). By comparing the Pre-test and Post-test, patients with Nil effect (p-value 0.66), Mild effect (p<0.0001), & Moderate effect  Comparison between both Mild and moderate effects (pre & post-treatment) was statistically significant (p<0.0001) (Table-3). 

Table 1: Distribution Based on Socio-Demographic Characteristics (n=130).

Figure 1: Distribution Based on Based on Emotional Aspects (n=130). Click here to view Figure

Table 2: Distribution Based on Symptom Severity Assessed by VSQ Score (n=130)

Table- 3: DISTRIBUTION BASED ON VDQoL SCORE TO ASSESS QoL (n=130)

Discussion

This study primarily aimed to determine the effect of VVC on the quality of life (QoL) among the women with VVC. According to the data obtained from socio-demographic details (Table-1); VVC was more prevalent among women in the reproductive age group 18-35 (37.6%). According to prior studies, women under the age of 40 had twice as high a risk of developing VVC as those over the age of 40 ¹¹. Based on a study by Dr. Meena Salvi et al., the age group of 26 to 30 years had the largest proportion of VVC (39.08%), followed by the age group of 31 years. The majority of women was involved in sexual activity and increased estrogen production during the reproductive period. Young women may be more vulnerable to harmful influences, such as risky sexual activities, which could reflect that VVC is more prevalent in this group ¹¹. Additionally, during this period of life, women experience physiological and tissue changes brought on by reproductive hormones that make them more vulnerable to Candida infection²². By the assessing the emotional characteristics of women with VVC, (96.1%) percent of them suffer anxiety and tension (Figure-1).  Anxiety and stress related information among  women with VVC is obtained  from the Data collected by using  the Data collection form.Thus according to David Miller et al., the following describes how the women experienced feeling in their condition: Aside from being humiliated (n=8, 28.6%), stinky (n=8, 28.6%), dirty (n=13, 46.4%), depressed (n=12, 42.9%), anxious (n=10, 35.7%), unattractive/unsexy (n=9, 32.1%), stressed (n=10, 35.7%), unattractive/unsexy (n=9, 32.1%), frustrated (n=20, 71.4%), and isolated Thus according to Roksana Janghorban et al, there is a high correlation between depression, anxiety, and stress in addition to a history of RVVC. This result suggests that RVVC patients experience higher levels of stress, anxiety, and depression than healthy individuals ¹³.  According to the study conducted by Shang-Rong Fa ; Of these women, 68 % reported depression/anxiety problems during acute episodes and 54 % reported depression/anxiety when they were not experiencing episodes, compared with less than 20 % for the general population²⁰. it was stated that depression and anxiety are more common in these patients and, in evaluations made with FSFI, there are often variations in satisfaction scores, especially concerning hirsutism and BMI (4,5)²³.

A study by Gulsum Uysal et al, women with RVVC” reveals more stress than healthy controls report, and lifestyle factors and long-term stress both might influence the development of RVVC.  Moreover, long-term stress and work-related stress symptoms were much more prevalent in women with RVVC ¹⁴. Thus according to studies by Marwa Reda Rashad et al., the vaginal infected women were most likely to have an impact on emotional well-being and role limitation due to physical problems ³. Decreased orgasms and sexual satisfaction influence women’s mental well-being, causing stress, worry, and depression to rise. As these issues develop, they might have an effect on the immune system, make the body more vulnerable to infections, and eventually result in an increase in RVVC. According to the study’s findings, these women’s sexual function status had a negative relationship with mental issues (anxiety, stress, and depression). Consequently, these criteria of mental health are likely to be worse if the status of sexual function has a lower score ¹³. From the study conducted by Samuel Aballéa e tal; Around 50% of the RVVC sample claimed the disease impacted their daily normal activity (from 45% for UK to 60% for USA). In addition, working women with RVVC missed around six hours of work per episode of yeast infection¹⁶.

In this study; the severity of symptoms in patients with VVC is calculated by using the Vulvovaginal symptom questionnaire (VSQ). Before the treatment, 26.1% had greater than 10 severity scores, and 74.6% had lesser than 10 severity scores. After the treatment, 7.6% had a greater than 10 severity score (p-value 0.98), and 92.3% had a lesser than 10 severity score (p<0.0001).On comparing the symptom severity (Score ≤10) between pre-treatment & post-treatment (p<0.0001), statistically significant. From the obtained data; the severity of symptoms (<10 score) affected by major percent of women (Table-2)

The severity of symptoms in VVC patients is determined by using Vulvovaginal Symptom Questionnaire (VSQ). The VSQ needed 21 elements to create it. The Vulvovaginal Symptom Questionnaire is utilized to determine the severity of symptoms in VVC patients (VSQ). Erekson et al created the 21-item VSQ to measure vulvovaginal problems from the prior week. There are 21 items overall, which are divided into four subscales: symptoms (items 1–7), emotions (items 8–11), life impact (items 12–15), and sexual effect (items 16–21). (Items 16-21). Each question has a yes/no choice and a probable score of either 1 or 0. Each subscale’s scored elements are combined to provide a total subscale score. The sum of all scored items creates the final VSQ score. The assessment of score on the 21-item VSQ in sexually active women (some who respond “Yes” to question 17) range from 0 to 20, with scores higher indicating higher vulvovaginal symptom distress. The response to Question 17, which asks about reporting current sex with a partner, is not included in the total result. The final four questions about the impact of vulvar symptoms on sexual activity are ignored. For women who aren’t sexually active with a partner, the VSQ scores range from 0 to 16, with higher scores indicating greater symptom severity ⁷. This 21-item Vulvovaginal Symptoms Questionnaire (VSQ) is to assess the effects of vulvovaginal symptoms on women’s quality of life. This psychometrically approved questionnaire evaluates women’s vulvovaginal symptoms and symptom-related quality of life in the past week according to daily life, social activities, social relationships, sexual activity, and one’s feelings about their vulvovaginal condition.This particular questionnaire examines the emotional state, daily activities, and symptom severity of patients with VVC²⁴.

Among the total of 130 participants, Quality of life (QoL) is determined by using the Vulvar disease quality of life index questionnaire (VDQoL). Before the treatment; 1.1% had a Nil effect, (60%) had a Mild effect, Moderate (37.6%), and Severe(2.3%). After the course of treatment, their QoL is determined by administering the same questionnaire to the patients. 2.2% having a Nil effect, 90.7% having a Mild effect, and Moderate (7.69%). By comparing the Pre-test and Post-test, patients with Nil effect (p-value 0.66), Mild effect (p<0.0001), & Moderate effect (p<0.0001). Comparison between both Mild and moderate effects (pre & post-treatment) was statistically significant (p<0.0001)(Table-3). The majority of women having mild effect of VVC on their quailty of life. The Vulvar Disease Quality of Life Index is utilized to evaluate the Quality of Life (QoL) . The 15 questions in the VDQoL; can be scored as 0(“not at all”), 1 (“a little”), 2 (“a lot”), or 3 (Very much”). The total score ranges from 0/45 to 45/45, which could be interpreted as follows: A total score of 0-5 indicates the VVC has little to little impact on the quality of life, 6-13 implies a mild effect, 14–23 a moderate effect, 24–37 a severe impact, and 38–45 a very severe impact⁸.

From the results obtained, it is revealed that the VVC has an impact on the emotional aspects like anxiety and stress ,and also it influences the Quality of life (QoL) of the patients affected by VVC. The Quality of life and symptom severity in the patients with VVC is determined by using VSQ & VDQoL questionnaire.

Conclusion

The study concluded about the influence of Vulvovaginal candidiasis (VVC) on the quality of life (QoL) of the women diagnosed with VVC. The severity of symptoms and QoL; determined by using VSQ and VDQoL  questionnaires. From obtained results it can be concluded that the emotional aspects like anxiety and stress were present in  women diagnosed with VVC . From the results gained; it can concluded that the VVC have a mild-moderate effect in the Quality of life of women. Vulvovaginal candidiasis have a negative impactt in the emotional aspects and QoL of the patients.

Acknowledgement

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

Conflicts of Interest

No conflicts of interests declared by the authors.

Funding Sources

There is no funding sources.

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