Introduction

Vulvovaginal candidiasis (VVC) is a prevalent vaginal infection that affects around 70 -75% of women of reproductive age with at least one episode in their life, and up to 50% of women experience recurrency than known as recurrent vulvovaginal candidiasis (RVVC)^1,2. For that and other reasons like its unpleasant experience including discomfort, interfering with sexual and work activities, World Health Organization (WHO) considered vulvovaginal candidiasis as pathological condition mainly of sexually transmitted in nature and received an ongoing concern as one of a public health problem³.

The main cause of VVC is the abnormal growth of fungi in the mucosa of genital tract leading to infection that characterized by intense vulvar itching, leucorrhea, dysuria, dyspareunia, vulvovaginal edema and erythema. Approximately 80-90% of VVC cases are caused by Candida albicans and that only 10-20% of cases are caused by other Candida species known as non-Candida albicans species like Candida glabrata, Candida tropicalis or Candida krusei. The yeast-like fungi that considered as normal microflora in vagina become pathogenic when its colonization site become favorable to their development^4-6.

Several factors have been supposed to increase the developing risk of VVC, such as the previous colonization by the yeast, immunosuppressive diseases (HIV), pregnancy, diabetes mellitus (DM), hygienic behavior and other factors including the use of contraceptives^7-10.

Contraceptives are substances that are used as a measure for avoidance of unintended pregnancies. There are several forms of contraceptive methods includes oral contraceptive pills, intrauterine devices, and injectable contraceptives (Depo-Provera), vaginal tablets and cervical caps 4. The hormonal contraceptives comprise estrogen and progesterone hormones which increase the vaginal glycogen that converted into lactic acid via lactobacilli leading to decreasing in intravaginal pH level and consequently facilitate the overgrowth of Candida^8,11.

Hormonal contraceptives particularly oral contraceptive pills and injectable contraceptives are highly widespread as well as broadly available method of contraception in Iraq that reach up to 70% among other contraceptive methods¹², and therefore it may be increasing the risk of developing vaginal candidiasis. Thus, this study aimed to determine the association between the use of hormonal contraceptives and development of vaginal candidiasis infection.

Subject and method

This cross-sectional design study was conducted to investigate the prevalence of vulvovaginal candidiasis caused by Candida species among contraceptive’s users. The vaginal swabs were collected from 270 women who sexually active and complaining from vaginal discharge and attending the outpatient’s clinic of Obstetrics and Gynecology at Medical City, Baghdad from January through December 2020. This study’s sample consist of 202 women who were contraceptive users and 68 women who were not using contraceptives. Pregnant women and those with diabetic mellites or underlying immunosuppression or those with previous history of candidiasis were excluded from study.

Details regarding clinical history and full examination were recorded beside vaginal examination via Cusco's speculum to examine the vagina and cervix and looking up for any pathology such as discharge, erosions, vaginitis, cervicitis in addition, the color, character, amount and smell of the vaginal discharge were also observed. Then, vaginal discharge was collected using three swabs from the upper third of the vaginal walls and sent for culture at educational laboratories of Medical City that processed for inoculation in culture media, wet mount microscopic examination, and for gram staining to find Candida and identify its species.

Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26.0. Standard approaches of frequencies and percentages were used for quantitative data. Chi-squared test were used to assess the associations between categorical variables of contraceptive users and non-contraceptive users regarding isolation rate of Candida and its species.A . value of <0.05 was considered a significance level for any test throughout the study.

Results

A total of 270 women were recruited in the study behind the inclusion and exclusion criteria, their age was ranged from 15 to 45 years with mean of 28.35$\textcolor{red}{}\pm$8.494 and more than one thirds were at the age group of 20-30 years old. About three fourths of study’s sample were found to use one of the contraceptive methods (74.8%), of which, 73.17% were found using combined oral contraceptive pills (COCP), 17.3% were using injectable method, and only 8.41% of women were using an intrauterine contraceptive device (IUCD) (Table 1).

Out of 270 women with vaginal discharges, 145 (53.7%; 95% CI: 40.4- 52.2) were found to have positive vaginal culture. Candida albicans was the most frequent species isolated among positive culture study’s sample (71.7%), followed by Candida glabrata, Candida tropicalis, Candida krusei, Candida famata, Candida ciferrii and Candida lusitaniae (10.3%, 8.2%, 2.8% and 2.1%) respectively (Figure 1).

Figure 1
Prevalence of positive candida culture and its species among studied women with vaginal discharge.

A significant difference was found between contraceptive women and those who were not using contraceptives( Importar imagenCI: 14.448, df: 1, P = 0.000), as women who use one of the contraceptive methods were more likely to suffer from Candida infection of the vagina than those who did not use it (84.1% vs. 15.9%) respectively (Table 2).

: 14.448, df: 1, . = 0.000

Similarly, Candida species were significantly more prevalent among contraceptive users’ women than those who were not using contraceptives; Candida albicans (75.41% vs. 52.17%), Candida tropicalis, Candida ciferrii, and Candida famata (each 75% vs. 25%), Candida glabrata (73.3% vs. 26.7%), Candida krusei and Candida lusitaniae (each 66.7% vs. 33.3%) respectively

=19.485, df: 7, P=0.007) (Table 3)

: 19.485, df: 7, P = 0.007

*Only women with positive candida culture.

Furthermore, the vaginal candiasis was significantly more prevalent among women who were using combined oral contraceptive pills (COCP) than those who were using injectable or intrautrine contraceptive devices (IUCD) (90.16% vs. 6.56% vs. 3.28%) respectively ( Importar imagen:53.676, df: 3, P = 0.000) (Table 4).

: 53.676, df: 3, . = 0.000

Likewise, candida species were more prevalent among women who using combined oral contraceptives pills than those who using injectable or intrauterine contraceptive devices (. < 0.01) (Table 5).

: 74.058, df: 21, . = 0.000

*Only women with positive candida culture.

Discussion

The prevalence of vaginal candidiasis among study’s sample was 53.7%, of which, the Candida albicans species was being the dominant (71.7%) and such findings are within the range that were reported in the literature^1,2,4,6,8. However, our rate was identified to be higher than what were reported by other studies^13,14 and such differences could be attributed to the differences in research method with adopted inclusion and exclusion criteria.

The study found significant differences between contraceptive women and those who were not using contraceptives regarding their candida infection, as vaginal candidiasis was more prevalent among contraceptive users’ women as compared to non-contraceptive users’ women (84.1% vs. 15.9%) respectively, and such finding is in consistence to what were reported by other studies^8,13,14. Moreover, all Candida species were found significantly more prevalent among contraceptive users’ women as well as Candida albicans was identified to constitutes the higher proportion and such results are supported by other studies^13,14.

Amidst contraceptives users’ women, a higher proportion of Candida infection was significantly observed in combined oral contraceptive pills users as compared to those using injectables or intrauterine contraceptive device (90.16% vs. 6.56% vs. 3.28%) respectively, with Candida albicans species found to be a predominat on the other Candida species for COCP than other contraceptive methods used, and such results coinciding with the results of other literature^8,14 that reported a higher prevalence of vaginal candidiasis among oral contraceptives users’ women than non-contraceptives users’ women.

Conclusion

According to evidence revealed in this study, there is a strong association between the prevalence of candida infection of the vagina and its Candida species and the use of contraceptives, where the Combined Oral Contraceptive Pill (COCP) is the most influencing method of contraceptives that contributes to the vaginal candidiasis

conflicting interests

Authors disclose that, there is no potential conflicting of interests is exist for such self-funding project.

Acknowledgments

The authors would like to thanks all women who participated in this study.

References

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Notas de autor

reem_haddad@aliraqia.edu.iq