Self-medication with vaginal antifungal drugs: physicians’ experiences and women’s utilization patterns Sinikka Sihvoa,b, Riitta Ahonenc, Heli Mikanderc and Elina Hemminkia
Sihvo S, Ahonen R, Mikander H and Hemminki E. Self-medication with vaginal antifungal drugs: physicians’ experiences and women’s utilization patterns. Family Practice 2000; 17: 145–149. Background. In many countries, vaginal antifungal drugs have been released on over-the- counter (OTC) markets, yet little is known about women’s management of their symptoms. Objectives. The aim of this study was to judge the appropriateness of self-medication with vaginal antifungal drugs by examining utilization patterns and physicians’ experiences of women’s self-medication. Methods. An anonymous questionnaire survey was carried out in 20 pharmacies in Finland of women buying OTC vaginal antifungal drugs in 1997. Out of the 453 questionnaires distributed, 299 (66%) were returned. A survey of a random sample of gynaecologists (n = 169) and special- ists in general practice (n = 288) was carried out in 1996. The response rate was 77%. Results. Nearly all women had used vaginal antifungal drugs previously, 49% during the pre- vious 6 months. Most women did not report any difficulties with treatment, but 44% of women used the drug against recommendations. Half of the women had symptoms that are more likely to be related to infections other than Candida. Physicians had observed several disadvantages of self-treatment, with unnecessary use and use for the wrong indications being the most often reported. In all, 31% of gynaecologists and 16% of GPs reported that these adverse events had been clinically significant, with delay in the treatment of other infections being the most common problem. Conclusion. The results raise concerns about inappropriate use and women’s ability to self- diagnose correctly. Because vaginal antifungal drugs are likely to remain on OTC markets, two ways to address these concerns are for physicians and pharmacy personnel to provide spon- taneous information and to have more informative advertisements on vaginal antifungal drugs. Keywords. Miconazole, over-the-counter drugs, self-medication, vulvovaginal candidiasis.
clotrimazole) were released over-the-counter (OTC) in1991; these same drugs were released in the UK in 1992,
Vaginal Candida infection, a common problem among
and in Finland miconazole was released in 1993,
women, has been regarded as a minor complaint suitable
clotrimazole in 1994 and tioconazole in 1995.
for self-medication. It has been estimated that vaginal
According to labelling, vaginal antifungal drugs should
candidiasis affects ~75% of women during their lifetime,
be used under the surveillance of a physician in the
and ~40–50% of them have recurrent episodes.1 In
case of a first infection, if it is the third infection during
the USA, certain imidazole derivatives (miconazole and
the past 6 months, if the woman is under 16 years old or if it is during the first trimester of pregnancy.2 Thecrucial point for appropriate self-medication is that
Received 23 June 1999; Revised 15 October 1999; Accepted
the woman should be able to self-diagnose correctly. 26 October 1999.
Vulval and vaginal itching (pruritus) is the most common
aStakes (National Research and Development Centre for
symptom related to Candida. Other possible symptoms
Welfare and Health), POB 220, 00531 Helsinki, bUniversity of
(white, thick discharge, dysuria, vulval erythema and
Helsinki, Department of Public Health, POB 41, FIN-00014
swelling) can be related to many vaginal infections other
University of Helsinki and cUniversity of Kuopio, Departmentof Social Pharmacy, POB 1627, 70211 Kuopio, Finland.
than Candida (e.g. bacterial vaginosis, trichomoniasis,
Family Practice—an international journal
Chlamydia, gonococcal infection, herpes simplex or
specialists in general practice (n = 288) in six of the
allergies).1,3–5 It has been suggested that most vaginal
12 Finnish counties between June and September 1996.
symptoms are treated as Candida infection although
The sample was selected from the national register of
bacterial vaginosis is more common.6 In a 1996 survey,
healthcare professionals by listing all physicians by zip-
Finnish physicians held a positive view about the OTC
codes and then picking every other physician. To make
release of vaginal antifungal drugs and considered
reminders possible, each respondent was asked to send
miconazole to be suitable for self-medication,7 like their
their name tag in a separate envelope. After a reminder,
British colleagues in 1994.8 American physicians’ per-
351 questionnaires were returned, of which 10 were ex-
ceptions about the reclassification of vaginal antifungal
cluded because the physicians were no longer in clinical
work or had changed to other specialties. The response
The purpose of this study was to estimate the appro-
rate was 77% for both GPs and gynaecologists. The
priateness of self-medication with vaginal antifungal drugs
mean age was 47.5 (SD 7.8) years among gynaecologists
by examining women’s utilization patterns and physicians’
and 46.5 (6.4) years among GPs. In both groups, about
observations of adverse events due to self-treatment.
The questionnaire included questions on opinions on
OTC releases in general7 and more detailed questions
about OTC vaginal antifungal drugs. The questions usedwere related to physicians’ experiences of problems due
to patient self-medication with vaginal antifungal drugs:
A sample of 20 out of 795 pharmacies in Finland was
“Have you observed in your work any of the following
picked from different areas to represent different clien-
adverse events due to the use of OTC vaginal anticandida
tele. All selected pharmacies agreed to participate. In
drugs?” (i) No; (ii)Yes, sometimes; (iii) Yes, often; and
each pharmacy, a questionnaire was given to consecutive
(iv) Cannot remember (listing eight adverse effects,
customers buying OTC vaginal antifungal drugs during
see Table 3). Also: “Have any of the adverse effects
October and December 1997. The woman filled in the ques-
you have observed been clinically significant?” (i) No;
tionnaire at home and mailed it to the researcher. Depend-
(ii) Yes, which ones? The chi-square test was used in
ing on the pharmacy’s size and location, each pharmacy
statistical testing of differences in both data sets.
distributed 10–50 questionnaires. Altogether, 453 question-naires were distributed and 299 (66%) were returned.
The criteria for possible inappropriate self-medication
were defined as follows: (i) never had a physician-diagnosed Candida infection; (ii) age under 16 years;
(iii) used during pregnancy without recommendation
The mean age of the women using vaginal antifungal
from a health care professional; or (iv) at least two pre-
drugs was 35 years (SD 11.1), ranging from 15 to 77 years.
vious treatment episodes during the previous 6 months
The women came from all social classes (according to
but no physician consultation during the past year. The
education) and 66% of them were in a steady relationship.
symptom profile was determined with the following
They had more often had two or more sexual partners
question: “Have you had any of the following symptoms
during the past year (20% versus 13%, P Ͻ 0.01) and had
during the past 2 weeks?” (i) No; (ii)Yes, but not trouble-
a higher lifetime incidence of sexually transmitted
some; or (iii)Yes, troublesome (with a list of 12 symptoms
diseases (STDs) than Finnish women in general10 (20%
listed, see Table 2). The proportion of women having
symptoms more likely to indicate infections other
Miconazole products were purchased most often
than Candida was defined according to the medical
(44%), followed by clotrimazole-containing products
literature.1,3,4 Structured questions were used to study
(35%) and tioconazole (17%). Half (49%) of the women
decision-making (“Was it easy to conclude what these
had used antifungal drugs already during the previous
symptoms result from?”) and healthcare-seeking (“If
6 months and 29% had had a vaginal Candida infection
the product would not have been available without a
diagnosed by a physician during the past year (Table 1).
prescription, would you have visited a doctor?” and
Forty-four per cent of the women were classified as using
“Which doctor would you have visited?”).
the drug against the recommendations: 14% had never
The sexual health profile of antifungal drug users was
had a physician-diagnosed Candida infection, 30% had
studied by comparing them with Finnish women from a
already used two or more treatments without contacting
population-based survey, FINSEX-1992, which included
a physician during the previous year, 3% were pregnant
women aged 18–74 years (n = 1144).10
but had no professional recommendation for use, andtwo users were under 16 years of age.
Nearly all women had experienced vulvovaginal
Anonymous questionnaires were sent to a random
itching (Table 2). Stinging and increased discharge were
sample of working-age gynaecologists (n = 169) and
also common symptoms, but less often found to be
Self-medication of vaginal CandidaFrequency of vaginal Candida drug use and physician’s
earlier diagnosis of Candida or STDs had no effect on
women’s reports of symptoms requiring a physician’sevaluation. About a quarter (24%) had experienced
symptoms for 2 days or less (open-ended question) and18% for a week or more before buying the drug.
The majority (79%) of women said that it is easy to
determine the causes of their symptoms, 12% found it difficult and 10% could not say. Self-diagnosis was
more difficult for those women who had never visited a
physician due to vaginal symptoms (21%, P Ͻ 0.05) and
for those who had had symptoms for at least a week
(22%, P Ͻ 0.01). Nearly half (46%) of the women stated
that they would have contacted a physician immediately
if antifungal drugs had not been available OTC. Another
49% would have waited for a couple of days to see
whether the symptoms would ameliorate by themselves
before contacting a physician, and only 4% would not
have contacted a physician or could not answer the
question. Most women would have contacted a GP in a
public health centre (46%) or a private gynaecologist(45%).
a Two women did not give their age. b “Don’t remember” responses (3%) not shown in the table. Physicians’ observations of disadvantages of self-medicationGynaecologists more often than GPs reported seeing
Proportion (%) of women having had symptoms during the
adverse events due to self-medication with vaginal anti-
previous 2 weeks (n = 299)a
fungal drugs (95% versus 74%, P Ͻ 0.01). Unnecessaryuse and use for the wrong indications were the most
commonly mentioned adverse events (Table 3). Private-
sector gynaecologists reported adverse events mostoften. Both female GPs and female gynaecologists
Symptoms likely to indicate Candida infection
reported seeing adverse effects more often than their
In the subsequent question that explored the sig-
nificance of these adverse effects, 21% of all physicians
stated that some of the disadvantages they had observedwere clinically significant. Problems were identified
more often by gynaecologists than by GPs (30% versus
16%, P Ͻ 0.01), more often by female than male doctors
Symptoms likely to indicate another infection
(28% versus 15%, P Ͻ 0.01) and more often by private-
sector physicians (45% versus 18%, P Ͻ 0.001). The
most commonly mentioned clinically significant problemswere misdiagnosis and resultant delays in treatment
(12%) and delay specifically in the treatment of STDs
a Responses to a structured question, symptoms classified afterwards
Our results show that most women using antifungal
according to the literature (see Methods).
drugs had at some time had a vaginal Candida infection
diagnosed by a physician and that they did not report anyproblems in self-diagnosing or self-medicating; a similar
troublesome. Half of the women had symptoms that
result was found previously among American college
could be caused by infections other than Candida. A
students.11 However, a notable number of women used
quarter of the women (25%) had symptoms which called
OTC drugs against the recommendations: many used
for physician consultation. Women’s age, education and
antifungal drugs for the third time in 6 months without
Family Practice—an international journal
Physicians’ experiences of adverse events due to self-medication with OTC vaginal antifungal drugs (%)
Chi-square test, df = 2, ***P Ͻ 0.001, ns = not significant.
consulting a physician or without ever having had a
et al.5 Candida albicans is the major causative pathogen
physician-diagnosed Candida infection. Further, half of
in candidiasis. However, infections increasingly are
the women reported symptoms that are not typical of
caused by non-albicans species. The 1- to 3-day
Candida infection, but can indicate other infections. The
imidazole regimens will suppress C.albicans, but may
evaluation of the appropriateness of self-medication by
create an imbalance of flora that facilitates an over-
classifying symptoms based on the medical literature
growth of non-albicans species against which imidazoles
and women’s own reports is an imprecise method. There-
fore, these results have to be taken only as suggestive.
The drawbacks found have to be weighed against the
However, our results support earlier studies12 and case
benefits resulting from better availability of treatments
reports13 on problems with self-diagnosis. Ferris and
and the current satisfaction of the women and physicians.
co-workers12 have shown that prior clinical diagnosis of
To decrease the problems raised by these two surveys,
vaginal candidiasis only moderately affects women’s
more complete information should be provided for
ability to diagnose vaginal Candida infection correctly.
women. Advertisements can maintain the erroneous belief
On the other hand, one can question whether a woman
among women that if you have some of the symptoms
is likely always to be diagnosed correctly by a physician:
listed in the advertisement, you have Candida. Women
O’Dowd et al.6 have shown that only half of the women
need information about all vaginal infections and their
in the UK were given a vaginal examination when
symptom profiles so that they can judge their risk of
contacting their GP because of vaginal symptoms. Signs
having an infection other than Candida. Pharmacy
and symptoms have been shown to have poor predictive
personnel should take more responsibility in preventing
incorrect self-diagnosis or continuous use. The physician’s
Taking into account the fact that most physicians
role in making the correct diagnosis and providing
considered antifungal agents suitable for OTC status,7 it
information remains important since most vaginal anti-
is surprising that they reported so many problems related
fungal drug users have at some time consulted a
to self-medication with these drugs. Their perceptions
about unnecessary use gains support from the statisticson medicines, which show increased consumption ofvaginal imidazoles after OTC release.14
Many physicians in this study were worried about
delayed treatment due to incorrect self-diagnosis, a result
1 Working Group of the British Society for Medical Mycology.
also found among American physicians.9 Some physicians
Management of genital candidiasis. Br Med J 1995; 310: 1241– 1244.
expressed their concern about the inefficacy of treat-
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Self-medication of vaginal Candida
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9 Taylor CA, Lipsky MS. Physicians’ perceptions of the impact of the
symptoms and signs in the diagnosis of vaginal infections.
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5 Horowitz BJ, Giaquinta D, Ito S. Evolving pathogens in
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11 Lipsky MS, Taylor C. The use of over-the-counter antifungal
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6 O’Dowd TC, Parker S, Kelly A. Women’s experiences of general
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12 Ferris DG, Dekle C, Litaker MS. Women’s use of over-the-counter
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28 de septiembre de 2011 COMUNIDAD UNIVERSITARIA CARIBBEAN UNIVERSITY BAYAMÓN, CAROLINA, PONCE Y VEGA BAJA ESTADISTICAS CRIMINALES 2010 La Ley 101-542 conocida en inglés como Student Right to Know and Campus Security Act o Jeanne Clery Act, requiere que se recopilen y divulguen las estadísticas criminales y además, se mantenga informada a la Comunidad Universitaria sobre los
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