The vaginitis monologues: women's experiences of vaginal complaints in a primary care setting
Introduction
Vaginal complaints are a common presenting problem in primary care settings. They are usually diagnosed as “vaginitis”, a general term that refers to inflammation of the vaginal wall generally caused by one of three disorders: yeast infections, bacterial vaginosis, and trichomoniasis.
Current approaches to the clinical management of vaginal complaints emphasize a disease model: the diagnosis of one of the three disorders and the elimination of the microbial pathogen associated with it (American College of Obstetrics and Gynecology, 1996). Vaginitis is described as a non-debilitating, self-limited condition, which is treated effectively by antibiotics (Sobel, 1997). Yet even on its own terms, the infectious disease model appears inadequate to account for vaginal complaints in many women. Available tests lack specificity and sensitivity and there is a poor correlation between the identification of microorganisms and patients’ reports of symptoms. For example Gardnerella, the microorganism associated with bacterial vaginosis, normally inhabits the vagina; and many women testing positive for Candida or Trichomonas are entirely asymptomatic (Berg, Heidrich, Fihn, & Berman, 1983; Ohlemeyer, Hornberger, Lynch, & Swierkosz, 1999). Conversely, no infectious pathogen can be identified in a large proportion of women complaining of symptoms (Berg et al., 1984; Schaaf, Perez-Stabile, & Borchardt, 1990, Mayard, ka-Gina, & Cornelissen, 1998): fifty percent of women with symptoms remain undiagnosed even after extensive diagnostic workup (Schaaf et al., 1990). Furthermore, the presence of symptoms associated with vaginitis, including discharge (Stone & Gamble, 1959; Godley, 1985) odor (Doty & Huggins, 1975), and itching or discomfort (Priestley, Jones, Dhar, & Goodwin, 1997) do not necessarily indicate the presence of disease, since evidence suggests that these symptoms occur in the normal population.
In this study, we sought to investigate how women interpret vaginal sensations as symptoms and construct these symptoms as a problem requiring medical care. Studies of illness cognition suggest that people consider medical consultation when a bodily sensation is interpreted as abnormal and potentially threatening—that is to say, a symptom (e.g. Leventhal, 1989). The interpretive criteria used by an individual to distinguish a symptom from a non-symptom derives from the illness models currently available within a given social and cultural context (Shorter, 1992). In the case of vaginal complaints, one such model is the biomedical description of vaginitis.
Medical sociology has provided numerous examples in which modern medicine re-interprets normal manifestations of female anatomy and reproductive processes as disease, often resulting in the application of oppressive diagnoses and noxious treatments (Katz-Rothman, 1982; Martin, 1987; Scambler & Scambler, 1993). We wondered how the current medical model of vaginitis might influence symptom interpretation and treatment seeking, and whether women in our sample had experienced having a medical diagnosis of vaginitis imposed on what they had considered normal vaginal signs.
In addition, we investigated whether women drew on alternate medical or lay models in interpreting vaginal symptoms. Studies of treatment seeking have found that cultures differ in both the salience they attach to particular symptoms (Zola, 1963) and in the constellations of social factors that precipitate medical consultation (Zola, 1973). Given the symbolic significance of the vagina, we thought it likely that women's experiences with vaginal symptoms might be suffused with meanings related to sexuality, morality, and women's gender roles. Though there has been little research in this area (see Nichter, 1981) some evidence suggests that culture or ethnicity shape women's interpretations of vaginal normalcy and the significance of symptoms. For example, a study of African American and white American women found ethnic differences in patterns of treatment seeking for vaginal symptoms, suggesting that the two groups interpreted the significance of their vaginal symptoms differently (Foxman, Marsh, Gillespie, & Sobel, 1998). Studies from the ethnographic literature on South Asia report the existence of a syndrome in which “normal” vaginal discharge is re-interpreted by the patient as a sign of disease called “dhat syndrome”, precipitating extensive treatment seeking (Chaturvedi, Chandra, Isaac, & Sudarshan, 1993; Chaturvedi, 1993; Nichter, 1981). Data from a focus group study of Pakistani women with complaints of leucorrhoea, a culturally shaped disorder similar to dhat syndrome, indicate that the vagina is viewed as a particularly vulnerable, illness-prone organ, susceptible to the influences of weather, temperature, overwork, sexual dissatisfaction, and marital problems (Karasz & Anderson, 2001).
In addition to addressing the question of how women interpret their vaginal symptoms and the medical and cultural models influencing these interpretations, we had a second, more pragmatic goal in this study. We sought to document the experiential dimensions of vaginitis and its treatment that might have implications for improved clinical management. We analyzed women's illness narratives (Kleinman, 1988) for insights into the psychological and social sequelae of the disorder in order to discern whether women's social and emotional concerns were addressed through the treatment they received. Studies of doctor–patient communications show that such concerns play a major role in women's health seeking decisions. Yet they are often ignored during the medical consultation, in which the physician's biomedical agenda tends to dominate the interaction (Todd, 1989). One of the authors (MA) observed in his own medical practice that women presenting with vaginal complaints sought consultations and pelvic exams because they wished to determine whether their partners had been unfaithful to them. Presentations of vaginal symptoms often touched on issues of fear over sexual safety and anger over partners’ infidelity. We sought to explore such concerns systematically in our study and to investigate whether they were typically addressed in women's interactions with their physicians. Finally, we sought to learn how women judged treatment success and whether they were satisfied with the treatment they received in our clinic setting.
Section snippets
Study design
The study was carried out at the Montefiore Family Health Center, New York City, an academic community health center serving a multi-ethnic, largely working class population that includes many immigrants. We conducted semi-structured interviews with 44 women who had recently presented to a family physician or nurse practitioner and been diagnosed with vaginitis. Interviews were not taped; interviewers were trained to take in-depth notes. Six interviewers, including the authors and four medical
Symptoms
Eighty-five percent of women complained of some combination of itching (30/44), discharge (30/44), and odor (12/44). Four of the remaining seven patients complained of dysuria, two of non-specific pain. One woman was asymptomatic and had been diagnosed as having vaginitis by her provider. Other complaints included wetness, discomfort and a cut on the vaginal wall.
Diagnoses
Thirty-four women were asked what diagnosis they had received. Twenty reported being diagnosed with a yeast infection, five with
Discussion
The findings in the study provide insights into the current cultural models of female anatomy and disease that shape symptom interpretation and treatment seeking for vaginal complaints. We found evidence that the current medical model of vaginitis influences symptom interpretation, at least among women seeking medical consultation. According to the model, vaginal signs such as heavy discharge, itching and odor are associated with disease: many women in our sample concurred unquestioningly with
Conclusion
Our exploration of the experiential context of vaginal symptoms opened a door into the psychological and social worlds of these primary care patients. Patients’ psychosocial concerns, and the distress they occasion, has great importance for the care of vaginitis patients in primary care settings. Understanding what vaginal complaints “say” about social context could greatly increase physicians’ ability to provide care for their patient as a “whole person”. To do so it may be necessary to
Acknowledgements
Preliminary data from this study were presented at the North American Primary Care Research Group Annual Meeting in November 2000.
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