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Chronic vaginitis is a disease that affects women in so many ways. It’s uncomfortable, it’s embarrassing, and it affects their intimacy with their significant other. It’s reported that 50% of the women by age 25 have had at least one vaginal yeast infection.

Many women in the past were even reluctant to see their physician, typically a male gynecologist, about this problem. In my practice at Mitchell Medical Group, I have seen thousands of women who suffer from chronic vaginitis. I am not a gynecologist, but my approach is very different than most gynecologists, and I believe our success is due to a different way that we’re treating these patients.

Podcast main points & discussion.

Dr. Mitchell:

My guest today, Dr. Jack Sobel, is a top expert on chronic vaginitis, and he too is not a gynecologist, which I was even surprised to find out. I think he would most associate himself as an infectious disease specialist, but after reviewing his resume, he has training in multiple medical fields. And in fact, Dr. Sobel and I have a few things in common I realize. We both did medical work over in Israel. We both have infectious disease training because I did it in my fellowship. And we both ended up dealing with a lot of cases of Candida.

But Dr. Sobel is a true candida specialist and researcher. He’s done work at the NIH and other top institutions throughout his career. He has published a classic review paper in the New England Journal of Medicine on vaginitis back in 1997. And he’s really one of the preeminent authorities, so I’m just really excited to a lot of things I want to ask him. I believe he’s the Chief of Infectious Diseases at Wayne State University School of Medicine in Detroit, Michigan. So with that introduction, I’d like to welcome Dr. Jack Sobel to the podcast.

It’s nice to have you. Dr. Sobel, I enjoyed reading, there was an article about you in the Pfizer Discovery series and it was titled Not a Mycologist – Just Candida. And for our listeners, a mycologist is a fungal expert. It did reveal a lot to me about your interesting journey from a South African medical student and doing your residency there to post-graduate training in Israel, and then ultimately settling in the US for more specialty training and research. So my question to you to start out is, are you just a professional student, because I saw you did two years of pediatrics, one year of medicine, one year of nephrology, a year of cardiology, or is it you just have this insatiable curiosity about all the different fields of medicine? So, that’s where I want to start.

Dr. Sobel:

I think the latter. I am a professional, definitely a paid student, so I’m not acquiring any tuition costs.

Dr. Mitchell:

Well, you’re very fortunate because you could go broke that way. But it’s really funny. The person who was the chief of my infectious disease department at St. Luke’s Roosevelt Columbia in New York many years ago, it was very interesting. He was very similar to you. I think until he landed infectious disease, he had done a year of cardiology, a year of pulmonology, I guess until he realized… You know what? The funny thing, what he used to say? I think you might laugh about this. He used to get a little frustrated with infectious disease and allergy, because that was the department we were the head of. He goes, “We don’t have an organ that’s ours.” Because he was thinking about obviously the pulmonary people have the lungs and the cardiologists have the heart. But infectious disease or an allergy, it’s all over the body. But I think that’s what ultimately drew him to that field, because like you, he was interested in the more intellectual aspects of medicine. Am I getting that right?

Dr. Sobel:

So I don’t know about it being intellectual, but it’s certainly infectious diseases as you point out is we don’t own an organ. We deal as clinical consultants. We have to talk and provide consultation on infections in every anatomical site, so you have to be able to talk to a neurosurgeon and a neurologist. And you can’t simply talk about the infection, you have to be knowledgeable about urology. You have to understand exactly what the neurosurgeon does. You can’t discuss a shunting infection without understanding what a shunt is. So you have to have a very broad, broad foundation of base. There is nothing that is more demanding in terms of having this broad base than being a specialist in infectious diseases.

Therefore, what you sell is not a technique. It’s not a procedure. You are selling your knowledge, and this is a broad base cognitive function.

Secondly, in relation to that, infectious diseases requires diagnosis. And we live in an era where diagnosis has not become a preeminent requirement and demand of medical specialists or physicians in general. Diagnosis in the 1950s and ’60s and ’70s was everything. And the whole education process was stood on its head when we then left the diagnosis oriented education of students and the way we taught residents and so on to say, “No, no, no. It’s not so important you make the diagnosis. You have to move to a different system.” It became the problem oriented education system or PORE, P-O-R-E, problem oriented. This move away from diagnosis was, in my opinion, was a terrible mistake in the whole education process.

But you have to have a foundation of knowledge and the critical feature about infectious diseases is understanding causation. Now, causation is not a word we commonly use. We talk about causes. We don’t talk about two terms: causation and causality. And both of them relate to the fact that just because you find a microorganism, a germ, a bacteria, a fungus, or a virus in a patient doesn’t mean it’s the cause of the symptoms. You have to establish that the organism that you’ve identified is actually responsible for the clinical syndrome you see. So it takes diagnosis to a new level and that’s critical.

Dr. Mitchell:

You bring up a lot of really important points. I want to just share this with the listeners so they could really appreciate what you’re saying.  I’ll never forget one who was very interesting. One of my professors in Israel was telling a funny story. He was doing training at Mass General Hospital and he was by the bedside listening so carefully to the patient’s heart. And the other Fellows that were American kind of were laughing. These were cardiologists. “What are you listening to heart sounds so carefully? We’ll just get an echocardiogram.” But people don’t realize the subtleties that you can miss with that.

Why Are Some Women More Prone to Chronic Yeast Infections?

But I want to get back to something else, because it’s going to dive into our talk on vaginitis, which I know so many of the listeners and women want to know about.

But the $24,000 question as we like to say in the United States is, why are some women more prone to these chronic vaginal yeast infections than others? I mean, what’s your gut sense over many years taking care of patients? What do you think it is? I have my opinions, but I want to hear yours.

Let’s start with candida yeast infections. Let’s start with that. We will work at other ones, but the chronic vaginal yeast infections. When you’ve seen them, because again, you’re seeing as an infectious disease doctor, you’re not the first line. They’re going to their gynecologist or their family doctor. You’re coming in when they’re saying, “Gosh, I haven’t gotten better after months of whatever my doctor gave me.” What’s your sense of why these women are different than others?

Dr. Sobel:

So vaginal candidiasis, or candida vaginitis, or yeast infections of the vagina, it’s a genetic disorder. It is entirely a genetic disorder. You’re born with the right genes, you’ll never get a yeast infection. You’re born with the wrong genes, you’re going to be prone to yeast infections all your life. Period.

We’ve suspected a genetic basis for this for the last three or four decades, but there wasn’t evidence. All we had was occasionally a family history. A mother would tell you about her two daughters, or patient would tell you about her two or three sisters. All of them are prone to yeast infections.

One. And number two, then afterwards the next evidence was long before we did HLH and then the real host genetic testing, the next evidence came with the blood group abnormalities. But in the 1990s, the real breakthrough came when family studies, familial disorders were described of an entity called mucocutaneous candidiasis. These were families where the woman got oral, and esophageal, and vaginal, and skin, and nail infections due to candida. And you could do very good, thorough, detailed genetic studies, and it was totally clear. So, that first gave us the insights that this was probably a genetic disorder.

The difference between candida and hemophilia, or sickle cell disease, that these sickle cell disease and all these other hemophilia genetic disorders are monogenic. You need one gene to change and one mutation to be handed down from generation to generation. Candida is polygenic. It’s due to single nucleotide polymorphisms. It’s very minor changes without a mutation in multiple genes, which together build up a susceptibility. So, that they’re going to be women who go through life who never get a yeast infection ever. They take antibiotics. They do all the things you described earlier. They still never get a yeast infection.

So a woman is born with a genetic susceptibility. Depending on the number of polymorphisms she’s got, she’s going to be high risk on the basis of genetics, she’s going to be moderate, she’s going to be low risk, or she’s going to be no risk. She goes through this, and the genetic susceptibility applies at two levels. One is the risk of becoming colonized. In other words, yeast reaching her vagina and remaining there. One, there’s a variable risk of that happening. If you don’t have colonization, if you don’t have yeast in the vagina, you can take all the antibiotics in the world. You’re never going to get a yeast infection. You’ve got to be colonized. And the colonization risk depends on receptors in the cells lining the vagina. They’ve determined whether you’re going to be colonized or not.

Triggering Mechanisms that Cause Yeast Infections

Dr. Sobel:

But being genetically predisposed is not enough. You then go to the next level of the cause, and that’s called triggering mechanisms. Triggers. And you are only talking about the triggers. You’re not talking about the host susceptibility. The commonest trigger is antibiotics, and all antibiotics have this risk. Obviously the more frequently and the more prolonged your course of antibiotics, the higher the risk. But if you speak to most women who really do have recurring episodes of candida vaginitis yeast infections, they’ll tell you they get attacks without taking antibiotics. They’re getting episodes all the time.

So you separate triggers from underlying host susceptibility. But no question, antibiotics are a very high risk factor. Then there are other risk factors that may do it. For example, in a small percentage of women, it may be a dietary factor.

I’ll tell you, I’m very prone to yeast infections when I have a binge on ice cream or refined sugars.

Dr. Mitchell:

But that makes sense to you as an infectious disease, right? Because the candida loves sugar, loves simple carbohydrates, right?

Dr. Sobel:

That’s exactly right. Yeast is very, very glucose and other hexoses dependent. You are correct. So, that would be a second example of a trigger. A third mechanism is sexual activity. Frequency of intercourse, duration of intercourse. The friction involved often creates a low grade inflammatory process, which just facilitates the transformation in a woman who has no symptoms. Yet, she has yeast in her vagina that can trigger it. And you see it by when you take a careful history. So you’ll see Mrs. Smith. And she’ll say to you, “My husband’s been in the Marines. He’s been away for the last six months. I’ve had no sexual activity. I haven’t had a singular type of yeast infection. He came back home for 10 days and we’ve had a lot of sexual activity. And guess what? I knew within three or four days, I was going to get another yeast infection.”

Dr. Mitchell:

Oh, I hope you’re not leading to recommending the women will have celibacy. (laughs) That’s going to be a problem here.

Dr. Sobel:

No, no, no, no, no one’s recommending celibacy here, no. So, that’s the trigger in that patient. In other women who are prone to yeast infections, sexual activity has no role. So they are multiple triggers that you need the genetics to sit through.

Dr. Mitchell:

Okay. And one the things too, because I think you dispelled this in one of your articles… So diabetes, would you also say that is a predisposition? Cause I know in some of your articles, you kind of dispelled that.

Dr. Sobel:

Yeah. But if you take a hundred women who are having recurring episodes of yeast infection, maybe 2 or 3% will be diabetic, so the other 98% will not be.

Candida’s Role in Chronic Yeast Infections

Dr. Mitchell:

Let’s talk about an organism though, too. Also, do you find that… I mean, we know candida albicans is the predominant strain in many of these cases, but now we’re hearing more about something called candida glabrata and a few other ones. Are you finding that to be an issue in some of the more difficult cases to resolve?

Dr. Sobel:

Absolutely. So, as you point out here about 150 species of candida. About 10 of them tend to species are responsible… Certainly five species are responsible for 98% of the infection of which candida albicans in North America. Canada, USA, candida albicans is responsible for 90% of infections. Glabrata is responsible for 3 to 5%. That’s not the same all over the world. There are parts of the world, especially in the middle East and Africa where candida glabrata it can be responsible for 30 to 40%.

But in North America, it’s fortunately very, very low. But that’s important because glabrata is not as virulent, it’s not as aggressive, it’s not as dangerous as albicans. And women are more commonly colonized with glabrata, without it actually causing symptoms.

So when I find an asymptomatic woman comes to see me and she’s coming for a routine checkup or whatever it is, and I find glabrata on culture, I never treat her. Because it’s an organism that is doing her no harm, it’s not causing her any symptoms, and it’s a very difficult yeast to treat. I’m not certainly not going to tell her “I’ve got to get rid of this glabrata” when it’s not causing any symptoms.

What Causes Symptoms

Dr. Mitchell:

Again, with your background in infectious disease, and mine in infectious disease and allergen, I’m curious too, cause you seem to alluded to it also in one of your papers, that a lot of times the women that have what appears to be candida yeast vaginitis, do not have any candida there. And so, do you sense that it could be a hypersensitivity or like allergic type reaction that’s going on there in some of these case?

Dr. Sobel:

So you’re actually hitting and getting close to one of the two or three critical questions is, what causes symptoms?

With a heavy yeast, why are some woman colonized without symptoms? And other women, when they are colonized, they get symptoms? And that’s the difference between the yeast in an asymptomatic woman. And for the most part yeast in the asymptomatic form, will only have yeast as a stage called the blast of spore. They have the single cell organism that doesn’t bide, and it doesn’t form high fee, it doesn’t form long filaments. That’s the bundle itself. So when it’s in what we call the commensal phase, colonization without symptoms. The yeast is not being virulent. And that’s the very common sense scenario. And with evolution, women have developed over the centuries and hundreds of thousands of years, they tolerate yeast in the vagina, together with all the other bacteria that are present in the vagina. And normally, which tend to be in are most frequently lactobacillus species, the whole of the genital tract is what is called immunologically down-regulated system. In other words, because of the introduction with intercourse and ejaculation of foreign proteins, and who knows what else. But then the immune system of the vagina is down-regulated to tolerate these foreign proteins and not to react.

Otherwise, they wouldn’t be symptoms developing every time somebody had intercourse. That could interfere with pregnancy and so forth.

So, you say you have a physiological tolerance that exists in the vagina that allows yeast in low number to colonize and not to cause symptoms.

Dr. Mitchell:

Okay.

Dr. Sobel:

Women who have recurrent yeast infections, getting an attack every couple of months…

Dr. Mitchell:

Right.

Dr. Sobel:

Are more prone to becoming colonized because of genetic factors. And they don’t tolerate, they’ve lost the tolerance. So, what happens is that they no longer see the yeast in low numbers, as simple organisms that are causing it in each other.

Getting Diagnosed with Recurrent Yeast Infections

Dr. Mitchell:

The introduction of the podcast, this is a somewhat embarrassing condition for women and they’re sometimes reluctant into go to male doctors. Fortunately, there are a lot more women doctors and gynecologists now. So a lot of women self-diagnosed, and they could go over the counter and get things like Monistat or whatever, and try to treat themselves say hopefully… Like somebody would if they had a little rash. They’d get a little cream, a little cortisone cream and say, “Oh, I hope this goes away. I don’t want to have to make a big deal, go to the doctor.” But that’s not the case in these recurring cases.

So I want to ask you and say, as I said, I’ve reviewed your articles, which I’ve seen many of them, which I really enjoyed. But you also go through, again, some of these papers are older. You know all the classic ways to differentiate the different causes of vaginitis. The pH, obviously there’s something called, I think it’s the Ames test, and other things. But what I like when I see a patient, when they come from their gynecologist, I request that they do the PCR new swab, where I get the whole differential of the different things. Do you agree with me on that? Do you feel that’s a very helpful way of knowing specifically the organism? Or do you rely on some other tests that I should know about?

Dr. Sobel:

(laughs) So, the answer is the women when they go to a doctor, a gynecologist, infectious disease specialists, they deserve an answer and they deserve a diagnosis.

Dr. Mitchell:

And self-diagnosis by woman is unreliable.

Dr. Sobel:

Yes.

Dr. Mitchell:

Very unreliable. There are occasionally the occasional women who are very good at self-diagnosis, but that’s not the majority, one. Two, you can’t make a diagnosis, if you’re a physician, over the phone.

Dr. Sobel:

Correct. Not in this case you can’t. (laughs)

Of course, the symptoms are not specific. So, Mrs. Smith, who is prone to yeast infections goes home and her husband says, “Let’s go out tonight and they go to a place and there’s a hot tub.” They sit and they get into their bathing suits, or perhaps less, and they’re sitting in the hot tub. And the hot tub was very effectively cleaned with chemicals.

They did not want to get anything. They sit down there quietly, they have a good time, drinks and otherwise. The next morning she wakes up, she’s got itching and rawness and soreness and irritation. She thinks she’s got a yeast infection.

Now, she could have a yeast infection, but what very often she’s had an allergic reaction or hypersensitivity or contact dermatitis infect in the genital areas. There’s also the exposure to bromides growing, or whatever they could find.

So, the answer the symptoms are the same. The doctor has to make the diagnosis.

This is purely a contact dermatitis. Dermatitis vasculitis appears. So, the doctor owes it to the patient. And the patient should always also the doctor, “What kind of vaginitis do I have, and how sure are you of the diagnosis? And what if we’re diagnosed incorrectly?”

The first thing is you do a physical exam. You take a careful history, Always. You do a physical exam, always. Remember you called, but the gynecologist or the doctor can’t just look at the woman and do a speculum exam, and say “Oh Mrs. Smith, you obviously have dah, dah, dah, dah, dah.” Not even God can think that. You have to confirm the diagnosis.

Dr. Mitchell:

You’re saying you obviously, you do your history, physical exam, you actually do the pelvic exam.

Dr. Sobel:

Always, always.

Dr. Mitchell:

And what tests would you send out or would you send out the new swab? Do you send out for multiple cultures? I want to know exactly what you do.

Dr. Sobel:

I rely on traditional methods to get the vaginal pH. And in vaginal yeast infections the pH is normal. In contrast where the pH is elevated, you’ve got a very likely bacterial cause or trichomonas or something else. Now using my traditional methods, I don’t need the new swab, but there’s no question, I do a culture on every patient, which takes 10 seconds, which costs about $10 to $12, insurance companies pay for it, et cetera, et cetera. So with my old methods, microscopy, pH, et cetera, and the culture, I’m perfectly adequate. I don’t need the new swab.

Dr. Mitchell:

I was about to say, you seem a little bit entrenched. It’s like the old school doctors, I’m not saying it’s bad, to obviously pull out your stethoscope and do other things, but technology is helpful. I mean, it’s-

Dr. Sobel:

No, no, no, no. I understand the reality of the situation. Doctors don’t have microscopes. They don’t have time, et cetera, et cetera. If you don’t do what I do and send out a molecular test, and the new swab is one of the many molecular tests. And they’re all the same and they’re all very good and they’re all very reliable. The only problem is you don’t get an answer now. I give the patients an answer within a matter of minutes. Otherwise, unless I’m waiting for a culture. But variably the molecular tests, and certainly the molecular tests are very expensive. The other thing, by the way, when you’re doing microscopy and you’re in a clinic and you set the bar high, in terms of exam, in terms of competence and quality.

Closing Statements

Dr. Mitchell:

I think the good news and what the takeaway from this podcast is make sure, especially in these recurrent cases, then you get an accurate diagnosis because too often women are probably self-treating and not getting that definitive diagnosis, which would be so helpful and important. Dr. Sobel, I think also really pioneered the approach of a longer duration of treatment, because so many women, again, that I see that I’m sure he sees seem to get us to shorter course and too many relapses. And I don’t know, I probably have my disagreements with Dr. Sobel, but I do believe that external factors or triggers as he likes to say through diet and the use of antibiotics and certain medications, I believe make patients more prone to any illness, but specifically even with chronic vaginitis.

Dr. Sobel:

Remember this for every 10 women that I’ve seen for recurring vaginitis, chronic and recurring vaginitis, probably only 30 to 40% of infections. The other more than half, have other causes of this identical symptoms. So what the woman need to demand the doctors. They want and need a diagnosis.

Dr. Mitchell:

Okay. I think we’re going to leave it at that because I think that’s so important. Get that diagnosis and hopefully you’ll get better. So again, thank you for listening. Stay tuned. We’ve got some more great podcasts coming up in the next few weeks on COVID testing the real deal about what to get since so many of us want to travel. And we also have another one coming up in a few weeks on the end of food allergy with a Dr. Carry Madej. So anyway, thank you so much. Thanks Dr. Sobel.

About the Author – Dr. Dean Mitchell, M.D.

Dr. Dean Mitchell, M.D.

Dr. Dean Mitchell M.D. is a Board-Certified and Immunologist based out of NYC. He graduated from the Sackler School of Medicine and completed training at the Robert Cooke Allergy Institute in New York City. He is also a Professor of Clinical Immunology at Touro College of Osteopathic Medicine, a fellow of the American Academy of Allergy, Asthma and Immunology, and the author of Allergy and Asthma Solution: The Ultimate Program for Reversing Your Symptoms One Drop at a Time. Dr. Dean Mitchell, M.D. has also been featured in The New York Times, The Huffington Post, Fitness Magazine, Dr. Oz and News NY 1. Dr. Mitchell also hosts the podcast The Smartest Doctor in the Room – a combination of a lively, personal and in-depth interview with top healthcare specialists.

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