Many changes have occurred since the publication of the first edition of this book in 2007. Due to the continual development of increasingly sensitive gene amplification–based protocols, there have been major advances in the characterization of endogenous microbiota that populate the lower genital tract in women of all ages. Alterations in this microbiota in women with various vulvovaginal disorders have also been more clearly delineated. Concomitantly, there has been a large increase in our general understanding and appreciation of the different components of the innate and adaptive immune systems and their interactions. This has been paralleled by a more sophisticated appreciation of the immune mechanisms operative in the healthy female genital tract and the specific alterations that increase both susceptibility and consequences of various infectious and noninfectious disorders. Most importantly, there has been an increased appreciation of the interactions between host and microbe in the genital tract, and the importance of these interrelationships in the promotion of health or disease has been emphasized.
We are concerned that many of these recent scientific advances have not filtered down to clinical gynecologists, primary care physicians, and dermatologists with busy practices or to the residents and fellows of these disciplines. The incomplete understanding and appreciation of new knowledge in the field of vulvovaginal disorders will, unfortunately, deny their patients optimal care. A major impetus to write a second edition of this book was to try to reach busy clinicians, residents, or fellows by explaining advances in individual disorders in a manner that is relevant to their practice.
In this edition, we attempt to provide a scientific rationale for the care of patients with vulvovaginal symptomatology. To paraphrase Euclid’s counsel to Ptolemy I, there is no royal road to the care of patients with these problems. Each patient has an individual problem that often will require an investment of time and attention to assign a diagnosis properly and provide adequate and appropriate care. Our aim in this book is to provide suggestions for accurate diagnosis and care that will avoid ineffective treatments and discomfort and stress for these women.
This text offers a comprehensive approach to the subject matter. Physicians are biologists and use classification to achieve order in their patient contacts. Figure P.1, of an uncultivated forest glen, serves as an example of the lack of order in the presentation of patients with vulvovaginal symptomatology. It is an undefined picture with no clarity. In medical textbooks, this vague picture of nature’s disorder becomes transformed into the pattern of a geometrically planted nursery in which each row of seedlings and trees represents a defined clinical entity such as bacterial vaginosis, Candida vaginitis, and Trichomonas vaginitis (Figure P.2), each with proscribed symptoms, diagnostic findings, and treatment. Too often, the time-constrained physician arbitrarily assigns the patient to one of these three entities without proper testing. When the misdiagnosed patient fails to respond, she is assigned again to another of these three categories. In addition to these misclassifications, these three infectious categories do not account for all patients with vulvovaginitis.
This text will expand the list of diagnostic possibilities and provide techniques to achieve a correct diagnosis and treatment options. Finally, we de-emphasize the classical signs and symptoms of various vulvovaginal disease entities. These classical presentations do not apply to the majority of patients with vulvovaginal problems, and they take attention away from the growing number of asymptomatic women who have a sexually transmitted infection. In each of the chapters on vulvovaginal disease entities, detailed treatment options are presented. Details of therapy are provided, with particular emphasis on the nuances that can be applied in women who fail to respond to the original medication prescribed or who do respond and then become symptomatic again after the treatment has ended.
Be aware of the potential limitations of our insights. Chronic vulvovaginitis has been a stepchild of medical research around the world. In many cases, the pathophysiology of disease and optimal therapy are not yet established. Each research clinic has a distinct patient population and is likely to make independent observations and establish unique practices. Opinions and practices not referenced in this text to either a specific author or to some other publications simply reflect the authors’ research clinic experience of more than three decades. Now, we invite you to read on.