Our miniseries is coming to an end...I always hated the end of a good miniseries.  You get so comfortable with all the characters in the first few episodes, and then--poof!  End of show.  But, like "Roots", this is a miniseries with a message...and in this case the message is that we--as allergists--need to take responsibility for all allergic disease, and not pay "lip service" to allergic vaginitis (or other illnesses involving other target organs), and still call ourselves "allergists".  In that sense, my "example" of allergic vaginitis as something ignored is part of a much wider picture of other diseases that allergists have de-emphasized in our quest to become the Super-Asthma-Doctor.  What should we do?  Here's a specific suggestion:

Get involved with your local gynecologists, and seek referral of women with chronic recurrent vaginitis with current atopic histories, for starters.  Over the years I've worked with several savvy gynecologists on mutual cases--cases that would have never improved without the concurrent treatment of a gynecologist and an allergist (myself). Take a good allergy history, treat with SLIT, and watch the vaginal symptomatology improve.   In my experience, when you have a highly atopic patient with recurrent vaginitis issues, you are dealing with an allergic vaginitis issue until proven otherwise.  This would be a safe--and potentially very rewarding place--to start. 

In this miniseries I believe the primary actor--the allergist--has "set out" for most of the performance. We haven't seen hide nor hair of him/her...I have a dream of the allergist returning in a sequel to this original miniseries--as a major player--and not a two-bit actor.   Let's enter the miniseries now, and say "Play it again, Sam..."

Yeah, I know.  Some of you may have written in and suggested that I am too sarcastic; my cynicism about our profession is too great; that my satire on the allergy profession is too biting, that I am too bitter.  But hey, you could think of me like that ice-cold shower you take on the morning after a long night out--painful, hard-to-take, but in a way refreshing, and it gets the job done.  Nevertheless, there may be some merit in what you say, so...well, I hear ya, Ralph.  So I'm turning over a new leaf.  No more Mr. Bad Guy.  So here goes:  I would request that all of you allergists take a moment from your busy lives and please--pretty please, if you will--clear your desks (and minds) of your asthma inhalers, asthma patient education booklets, asthma medication samples, asthma peak flow meters and color charts, asthma guideline protocols, asthma posters, asthma questionnaires, asthma textbooks, asthma journals, asthma-tips-for patients brochures, asthma controller meds, asthma semi-controller meds, asthma ultra-controller meds, and begin to think about a topic too rarely discussed amongst colleagues and friends in our own little bronchospastic let's-control-asthma world--a topic so radical it's almost beyond bearing: 

allergy.

yes, allergy.  allergy  on another mucosal surface.  

Oops.  Sorry.  ...And I promised to turn over a new leaf...but hey...I've got liftoff, so I feel great...

  But honestly, In our eagerness to examine the respiratory tract, how many of us really take an allergy history with an emphasis on vaginal pathology?  I have.  For 26 years.  And I have to say it's been an eye-opening 26 years. You see, basically, the vaginal mucosa responds to same 3 things that the respiratory tract mucosa does:  allergens, irritants, and infections.  And these 3 items are not mutually exclusive, and may co-exist together.  Keeping this concept in mind has helped me in achieving perspective in observing  allergic vaginitis in my allergy patients.   The following observations have come from listening to patients, testing them, and following their treatment.

1.  True atopic sensitivity to Candida antigen exists. Allergic vaginitis may exist by itself, in clinical "isolation"  (like the child who "just" has rhinitis) but many times in my experience it is associated with coexisting respiratory tract disease.  Suspect allergic vaginitis with Candida sensitivity  when a woman has positive immediate (not delayed) reactivity to Candida antigen on prick or intradermal testing, and when she has a history of vaginal pruritis with repeated negative gynecological exams.  Often a woman will complain to her gynecologist of intense itching or burning but be subsequently told she that has "just a few yeast cells" (or none at all) on exam, and told she "shouldn't worry."  She then may use an OTC antifungal vaginal cream with some relief. If she has a seasonal component to any traditional allergic illness, she may note that the vaginal symptoms flare the same time as her respiratory tract flares. 

2.  The vaginal lining may be reactive to food antigens.   Typically, food yeast, dairy and wheat are frequent offenders in the allergic vaginitis patient, but just like with other target organs in the body, virtually any food may play a potential aggravating role.  And, just like the respiratory mucosa, if an allergic response goes on for a long enough time, subsequent infection can ensue.  For example, I have a nurse I've treated who could eat citrus in limited quantities--a small amt would give leukorrhea, and 3 successive days would result in a documented yeast vaginitis episode on multiple separate occasions. Remember that small amounts of food antigen can be present in semen (see Part I of this series for the reference on the case of a woman sensitive to walnuts who had anaphylaxis on one occasion after having sex with her husband who had ingested walnuts prior to intercourse).  Thus, the vaginal mucosa is getting exposure to small amounts of food antigens in a woman having intercourse with her partner.  If a female allergic patient has a severe food reaction (like to peanuts) it is critical that her sexual partner avoid eating this food prior to intercourse! 

3.  Seasonal allergic vaginitis exists:   Many women who have a seasonal flareup of their respiratory condition in the spring/summer may have a flare-up of yeast vaginitis as well at the same time.     

4.  There is an allergic "triad" of Candida-mold-food yeast hypersentivity:  Just like there is the "hyperlipidemia-hypertension-cardiac disease" triad, we have a triad of "mold-Candida-yeast" triad for our profession.  For example, Airola et al last year described "clustered sensitivity" in a patient with documented reactions between multiple molds and baker's yeast.  Savolainen et all in Allergy in 1988 pointed out "atopic patients primarily sensitized by C. albicans and S. cerevisiae may develop allergic symptoms by exposure to other environmental yeasts due to cross-reacting IgE antibodies" .  Clinically, when you encounter a patient with documented sensitivity in one of these three areas (i.e., mold, yeast, Candida), --be sure to check out the other two.    In my experience, you will be richly rewarded diagnosticaly if you do this.  There is an intimate relationship between mold exposure and allergic vaginitis:  For example, patient X, a biology teacher, is one of my patients.  After being outdoors and digging in the dirt collecting mushroom samples with her studies, she returned back to the classroom with her students.  She was astonished to find that  within minutes after the mushroom exposure she had intense vaginal pruritis and burning.  This was accompanied by mild (and more tolerable) nasal congestion symptoms. I have one other patient with an identical story.   

5.  Vaginal symptoms with protected intercourse may be related to latex condom sensitivity:  warn your latex sensitive female patients about latex condom useage in their partners!   

6.  Antihistamines may be helpful for allergic vaginitis:  Just as for allergic rhinitis, I have occasionally found that routine systemic antihistamine medications may be helpful for allergic rhinitis.  I have also have used custom-compounded cromolyn sodium in coca butter intravaginally applied to be helpful on rare occasions.  There is a case report by Dhaliwal et al on allergic vaginitis due to ragweed, in which no success was obtained with antihistamines for controlling symptoms, and for which prednisone was provided for the ragweed season, with complete control of symptoms. 

7.  SLIT immunotherapy for offending allergens can greatly help the woman with allergic vaginitis and reduce the incidence of yeast vaginitis: Over the years, I have employed treatment for allergic vaginitis in the same protocol as I use for treating allergic rhinitis or asthma:  Identify the precipitating allergens, irritant, and infectious factors, and treat appropriately, with emphasis on SLIT for allergenic sensitivity issues.  This has been a rewarding experience for my patients, as well as myself, since treatment of allergic vaginitis can symptomatically help the patient, as well as reduce the incidence and severity of recurrent yeast infections...

So what's with the horse with the blinders, you ask?  Judging from the title, you were expecting vaginas--not horses, right?  Well, the whole point of my last two entries is that the typical allergist is so hung up on the respiratory tract, he/she cannot look either left or right--just straight ahead, plodding down the 'ol dusty respiratory tract:  from the tip of the nose down to the last terminal bronchiole.  And in the process of "putting on the blinders", he/she morphs into an "asthma doctor"--and becomes less of an allergist than he/she was meant to be.  And frankly the horse is to be given more credit than allergists--at least the horse had the blinders put on him by someone else.  In our case, we put the blinders on ourselves.  As an "asthma doctor" we offer less services than a pulmonologist (no bronchoscopy, no respiratory tract skills for handling the severely ill asthmatic) and we offer less services as a "compleate" allergist.  In truth, by trying to be both things, we really become neither. 

Succinctly put:  if we want to be better allergists, then we better "take off the blinders" and look around at all the mucosal membranes in the body.  In my last journal entry, I promised that "I'll give one more simple example of an area we have shamelessly ignored, to the detriment of our practices and our patients..."  And so begins The Vagina Monologues

By the way, this really is a mini-series, so set your DVR's for the next 3 installments:

• Part I--The Vagina as an immunologically reactive organ
• Part II-Clinical relevance in everyday practice
• Part III Suggestions for the future

Part I--The Vagina as an immunologically reactive organ

As I mentioned in my earlier comments, curiosity is essential in being a better allergist.  And why should we be curious about an organ that is so far removed from the respiratory tract?  In truth, there are some compelling reasons:

• The human vaginal basal lamina contains macrophages, lymphocytes, eosinophils, plasma cells, and mast cells
• IgE antibodies specific to C. albicans, seminal fluid components, pollen and spermicides have been identified in vaginal fluids of women with recurrent vaginitis
• Prostaglandin E2 can be found in the vagina
• Vaginal smears containing eosinophils have been observed
• IgE induced histamine release is a potent inducer of prostaglandin E2 from macrophages, which in turn suppresses the cell-mediated immune response necessary to keep Candida albicans in check
• At least eight publications from 1920 to 1995 describe allergic vulvovaginitis due to pollens
• In 1978 Haddad (Perspect Allergy 1:2-3, 1978)reported the case of a woman allergic to walnuts who developed anaphylaxis on one occasion after intercourse with her husband, who had ingested walnuts prior to coitus.  Seminal fluid revealed the presence of walnut protein. 
• In 1988 Witkin identified Candida albicans specific IgE in vaginal washes 
• There are in the literature at least five case reports and five open studies, including 177 patients suffering from recurrent vaginal candidiasis who had been prescribed Candida albicans allergen immunotherapy.  These women had positive immediate skin tests to yeast and showed improvement ranging from 65% to 80% on immunotherapy
  

In truth, allergic vaginitis is a well-defined clinically significant entity; there was a superb review article on this by Moraes, et. all in our own Annals of Allergy in October 2000. 

Now, I ask you, are there any follow-up articles, excited comments amongst allergists, letters to the editors, or frequent articles or talks at allergy meetings on this subject?  Nope.  None.  Zippo.  Dead end.  No curiosity.  No interest.  Void.  Null set.  All I hear is the sound of .....loud snoring...You see, we've got those blinders on, and we're too busy plodding down the 'ol respiratory tract road...Our heads are as empty as a 2 year old cannister of albuteral in the hands of a status asthmaticus patient...As Moraes and the other authors point out:

..."resulting symptomatic candidal vaginitis would be a secondary consequence to a primary allergic vaginitis"  (my emphasis)

And of course I don't have to tell you how big a problem recurrent yeast vaginitis is for women.  Like the fact that upwards of 70% of the general female population can have a yeast infection yearly.  But we don't care about that do we? 

In effect, allergic vaginitis is an "orphan illness" which nobody wants to "adopt".  Certainly not the gynecologist--and rightfully so, since they are not allergists and are not familiar with the allergic nuances of mucosal membranes, or with immunotherapy.  However, we as allergists have a bigger responsibility to deal with this illness, and I am confident if we work together with gynecologists we can much more effectively help our mutual patients with this difficult problem...

The vagina--an immunologically reactive mucosal surface.  Think about it...think about the potential to help others...pull the inhaler out of your mouth and get involved with treating this issue...Talk to your local gynecologist...Talk to your patients...Think about it...and be curious...after all, enquiring minds want to know.