Evaluation of the effect of contraceptives on the prevalence of Candida species on vaginal candidiasis in Dhaka, Bangladesh

Abstract

p>This study was designed to find out the relationship between uses of different contraceptives and the prevalence of vaginal candidiasis. High vaginal swabs were obtained from 350 women in the age group of 15-45 years with vaginal discharge attending at Sir Salimullah Medical College Hospital, Dhaka, which comprised of 247 contraceptive users & 103 non-contraceptive users. A detailed clinical history and a thorough examination of all the cases were done. After making the clinical diagnosis, appropriate tests for diagnosing Candidiasis were done by using standard procedures. Of the 247 women of contraceptive users, Candida species was isolated in 140 (56.7%) cases compared to 32 (31.1%) from 103 non-contraceptive users (p value <0.001). Different species of Candida were isolated from 172 (49.1%) cases among 350 women of which C. albicans was found in 125 (72.7%) cases, C. glabrata in 29 (16.9%) cases, C. tropicalis in 13 (7.5%), and C. krusei in 5 (2.9%) cases. Among 173 oral contraceptive users, the isolation rate of Candida species was 120 (69.4%). This was followed by injectables (17, 12.2%) and IUCD (03, 2.1%) cases (p value <0.05). The study revealed a strong association between use of contraceptives and the prevalence of vaginal infection by Candida species of which C. albicans was the most common species (72.7%). Among all contraceptives, use of oral contraceptive pills (OCP) was found as the most common cause of vaginitis, next to which were injectables and IUCDs.

Bangladesh J Med Microbiol 2007; 01 (02): 61-64

DOI: http://dx.doi.org/10.3329/bjmm.v1i2.21511

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Bangladesh Journal of Medical Microbiology, 2007, vol.1, no.2 ISSN 2070-1810
Original Article
Evaluation of the Effect of Contraceptives on the Prevalence of Candida Species on Vaginal
Candidiasis in Dhaka, Bangladesh
Yusuf MA1, Chowdhury MAK2, Sattar ANI3, Rahman MM4
Abstract
Objectives: The aim of this study was to find out the relationship between the uses of different
contraceptives and the prevalence of vaginal candidiasis. Methods: High vaginal swabs were obtained
from 350 women in the age group of 15-45 years with vaginal discharge attending at Sir Salimullah
Medical College, Dhaka which comprised 247 contraceptive users & 103 non-contraceptive users. A
detailed clinical history and a thorough examination of all the cases were done. After making the
clinical diagnosis, appropriate tests for diagnosing candidiasis were done by using standard
procedures. Results: Of the 247 women of contraceptive users, Candida species was isolated in
140(56.7%) cases compared to 32(31.1%) from 103 non-contraceptive users. This is statistically
highly significant (P<0.001). Candida species were isolated 172(49.1%) cases among 350 women of
which Candida albicans was in 125(72.7%) cases, Candida glabrata was in 29(16.9%) cases,
Candida tropicalis was in 13(7.5%), and Candida krusei was in 5(2.9%) cases. Among 173 oral
contraceptives users, the isolation rate of Candida species was 120(69.4%). This was followed by
injectables 17(12.2%) and IUCD 03(2.1%) cases. This is statistically significant (P<0.05).
Conclusion: There is a strong association between use of contraceptives and the prevalence of vaginal
infection by Candida species of which Candida albicans was the most common species. Among all
contraceptives, OCP is the most common cause of vaginitis, next to which was injectables and IUCD.
[Bangladesh J Med Microbiol. 2007;1(2):61-66]
Keywords: Contraceptives; Candida albicans; Vulvovaginal Candidiasis; Non-contraceptive users;
Introduction
Vulvovaginal candidiasis is a common cause of vaginal infection. It is a primary or secondary
infection of the vagina involving Candida species with Candida albicans being a leading cause1. This
disease condition could be exacerbated by a change in the normal vaginal ecology2. At least one
episode of vulvovaginal candidiasis is reported in up to 75% of premenopausal women3.
Yeast is always present in the vagina in small numbers, and symptoms only appear with overgrowth.
Several factors are associated with the overgrowth of Candida species leading to symptomatic
infection in women. These include broad spectrum antibiotics, steroids, being in the luteal phase of the
menstrual cycle, nulliparity, the use of spermicides, uncontrolled diabetes mellitus, T-cell dysfunction,
1Dr. Md. Abdullah Yusuf, Lecturer, Department of Pathology, Government H.D.C., Mirpur-14, Dhaka
2 Prof. Md. Abul Quashem Chowdhury, Professor, Department of Microbiology and Immunology, BSMMU, Dhaka
3Dr. Abu Naser Ibne Sattar, Department of Microbiology and Immunology, BSMMU, Dhaka
4Dr. Md. Mostaqimur Rahman, Lecturer, Department of Microbiology, Rangpur Medical College, Rangpur
Corresponding Author
Dr. Mohammad Abdullah Yusuf, House# 271/8, Niribily Housing, Shankor, West Dhanmondi, Dhaka-1207,
Bangladesh. Phone numbers: +880-2-9146101; +880-1-817565830; E-mail: ayusuf75@yahoo.com.

Evaluation of Effect of Contraceptives on Vaginal Candidiasis Yusuf et al
62
pregnancy, high dose estrogens and contraceptives4. Recent therapy with broad-spectrum antibiotics
such as tetracycline, ampicillin, and oral cephalosporin is also a risk factor, presumably because it
eliminates the protective vaginal flora, especially lactobacilli5. Other factors that may increase the
incidence of yeast infection include using douches, perfumed feminine hygiene sprays, and topical
antimicrobial agents, and wearing tight, poorly ventilated clothing and underwear6. Contraceptives are
chemical substances used for birth control measures which include oral contraceptive pills,
intrauterine contraceptive devices, and injectable contraceptives-Depo-Provera, jellies, creams, foams,
vaginal tablets and cervical caps4. The contraceptives containing oestrogen and progesterone hormone
increase the glycogen in the vagina which converted into lactic acid by lactobacilli. Thus overgrowth
of Candida species occurs due to decreased pH. The most frequent symptoms of yeast infection in
women are itching, burning, and irritation of the vagina. Vaginal discharge is not always present and
may be minimal. The thick, whitish-grey discharge is typically described as cottage-cheese-like in
nature, although it can vary from watery to thick in consistency.
Hormone containing contraceptives especially injectable contraceptives and oral contraceptive pills
are very popular method of contraception in Bangladesh7. Its services are widely available in our
country. Depo-Provera (DMPA) is used by more than 15 million women in more than 90 countries
worldwide7. Thus, there is a great chance of vaginal candidiasis in the women using this contraceptive
method. The aim of this study was to find out the role of contraceptives on the prevalence of vaginal
infection caused by different Candida species.
Methodology
The present study was carried out to investigate the prevalence of vaginal discharge caused by
Candida species among the contraceptives users. High vaginal swabs were obtained from 350 sexually
active women in the age group of 15-45 years with the complains of vaginal discharge attending at
OPD of Obstetrics and Gynaecology department Sir Salimullah Medical College, Dhaka which
comprised 247 contraceptive users & 103 non-contraceptive users. A detailed clinical history and a
thorough examination of all the cases were done by using a Cusco's speculum which was inserted into
the vagina to visualize the vagina and cervix. Any pathology of vagina and cervix like vaginitis,
discharge, cervicitis, cervical erosions were looked for. The amount, colour, character and smell of the
vaginal discharge in the vagina were noted. The discharge was then collected by three sterile swabs
from the upper part of the posterior fornix and lateral vaginal walls. The swabs of vaginal discharge
were processed as under: One swab was used for inoculation into culture media; Second swab was
used for wet mount microscopic examination; Third swab was used for making smears for Gram
staining. Laboratory procedures: (a) KOH preparation: A drop of 10% KOH was added to the
vaginal secretions taken on a clean glass slide and mounted with a cover slip. Candida was identified
as highly refractile, round or oval budding yeast cells; (b) Gram staining: Smears were prepared by
the specimen and was fixed by flaming. Then the slide was stained by Gram’s Method8. The slide was
examined under microscope at 40× for the detection of strongly gram positive budding yeast cell,
hyphae and pseudohyphae; (c) Cultures: Culture was done on Sabouraud's dextrose agar media at 370
C for 24 and 48 hours which showed a growth of creamy, greyish moist colonies. Saline wet mount
preparation of the colony showed budding cells and pseudohyphae; (d) Species identifications: Then
the species identification was based on germ tube test8, sugar assimilation test9, and sugar fermentation
test9. Data analysis: All statistical analysis was carried out with the Statistical Package for the Social
Sciences (SPSS, version 10.0; SPSS Software Ltd. Bangladesh). A P value of <0.05 was considered
statistically significant. The significance value of isolation rate of Candida species from contraceptive
users and non-contraceptive users were determined by unpaired Student’s ‘t’ test and the prevalence of
Candida species among the different types of contraceptive were done by one-way ANOVA test.

Evaluation of Effect of Contraceptives on Vaginal Candidiasis Yusuf et al
63
Results
Of the 247 women of contraceptive users, Candida species was isolated in 140(56.7%) cases
compared to 32(31.1%) from 103 non-contraceptive users. There was a statistically highly significant
relationship (P<0.001) between the contraceptive and non-contraceptive users. This is shown in the
table I. Candida species were isolated from 172(49.1%) cases from 350 women. Out of 172 Candida
species, Candida albicans was the most frequently isolated species accounting for 125(72.7%) cases.
The second most isolated species was Candida glabrata which was in 29(16.9%) cases.
Table I: Rate of isolation of Candida species from 350 samples.
P<0.001 (Highly significant)
Candida tropicalis and Candida krusei was isolated in 13(7.5%) and 5(2.9%) cases respectively. This
is shown in the table II. The highest prevalence of vaginal candidiasis was found in OCP users which
was 120(85.7%) in out of 173 patients. This was followed by injectables and IUCD which was
17(12.2) and 03(2.1%) respectively. There was a significant relationship (P=0.002) between the type
of contraceptive used and the prevalence of vaginal infections by Candida species. This is shown in
the table III.
Table II: Different Candida species isolated from contraceptives and non-contraceptives users
Name of Candida
species
Candida spp. from
Contraceptive users
(n=140)
Candida spp. from Non-
contraceptive users
(n=32)
Total
(n=172)
No
%
No
%
Candida albicans
107
76.4
18
56.2
125(72.7%)
Candida glabrata
21
15
08
25
29(16.9%)
Candida tropicalis
09
6.4
04
12.5
13(7.5%)
Candida krusei
03
2.1
02
6.3
5(2.9%)
Total (n=172)
140(100%)
32(100%)
172(100%)
Discussion
The present study was carried out to investigate the prevalence of vaginal discharge caused by
Candida species among the contraceptives users. A total number of 350 women were selected of
which contraceptive users were 247 women and non-contraceptive were 103 women.
Patient group
(n=350)
Isolation of
Candida spp.
Negative
cultures
Total
No
%
No
%
Contraceptive users
(n=247)
140
56.7
107
43.3
247(100%)
Non-Contraceptive users
(n=103)
32
31.1
71
68.9
103(100%)
Total (n=350)
172(49.1%)
178(50.9%)
350(100%)

Evaluation of Effect of Contraceptives on Vaginal Candidiasis Yusuf et al
64
Table III: Prevalence of Candida species among Contraceptives users.
Name of
contraceptives
No of Samples
(n=247)
No of infected
(n=140)
No
%
No
%
OCP
173
70.0
120
85.7
Injectables
68
27.5
17
12.2
IUCD
06
2.5
03
2.1
Total
247
100
140
100
P<0.05 (significant)
Among 350 women, Candida species were isolated from 172(49.1%) cases. From the total of 247
women of contraceptive users, Candida species was isolated in 140(56.7%) cases compared to
32(31.1%) cases from 103 non-contraceptive users. Similar pattern of isolation was found by Enweani
et al10 who reported a prevalence of 51.5% from the contraceptives users in Nigeria. Out of 172
Candida species, Candida albicans was the most frequently isolated species accounting for
125(72.7%) cases. This is with the agreement of the result found by Hurley et al11 and Marcano et al12.
Enweani et al10 was also found a highest rate of isolation of Candida albicans (70.7%) from the
contraceptive users in Nigeria. The second most isolated species was Candida glabrata which was in
29(16.9%) cases. Candida tropicalis and Candida krusei was isolated in 13(7.5%) and 5(2.9%) cases
respectively. There was a significant relationship (P<0.001) between the type of contraceptive used
and the prevalence of vaginal infections by Candida species.
Among the women using contraceptives, a highest prevalence of 69.4% was observed in oral pill users
as compared to those using injectables and IUCD in 12.2% and 2.1% respectively coinciding with the
result of Misra et al13. Oriel et al14 reported a higher rate of prevalence of vaginal candidiasis in oral
contraceptives users than non-contraceptives users. Milson and Ferrsman15 earlier had suggested that
this could be attributed to the presence of estrogen and progesterone hormones in the contraceptives
that increased glycogen in the vagina, thus exposing it to the activities of lactobacilli. The lactobacilli
are widely believed to play a role in the conversion of glycogen to lactic acid thus decreasing the pH
of the vagina. The decreased pH reduces the activities of the bacterial biota a while favors the growth
of yeasts including Candida species10. Ryley16 postulated that the low prevalence rate in injectable
contraceptive users may be related to the induction of hormonal changes. The IUCD users accounted
for 2.1% of those from whom Candida species were isolated. This might be due to local changes and
secretions resulting from foreign body contaminating in the vagina17.
In this study, the results revealed a prevalence of 31.1% in the non-contraceptive users. This finding
suggested that there might be other causes for the high prevalence of vaginal infections in females
apart from the use of contraceptives that may further increase yeast infections. It could also be
attributed to sexual behavioral predisposition. This conformed with other reports incriminating natural
factors to be predisposing to candidiasis1. The low personal hygiene and ignorance and illiteracy in our
society may also partly explain this high prevalence.
Conclusion
Results of this study have revealed a strong association between the use of contraceptives and
prevalence of vaginal infection by Candida species. Oral Contraceptive Pill was the most influencing
contraceptives that cause vaginal candidiasis.

Evaluation of Effect of Contraceptives on Vaginal Candidiasis Yusuf et al
65
Acknowledgment: We especially thanks to Dr. Maksuda Forida Akter, Registrar, Gynaecology and
Obstetrics department, Sir Salimullah Medical College, Dhaka for the collection of the samples from
the patients.
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