{"doi":"10.1093/cid/ciaa267","title":"Syndromic Treatment of Women With Vulvovaginal Symptoms in the United States: A Call to Action!","abstract":null,"journal":"Clinical Infectious Diseases","year":2021,"id":644796,"datarank":0.7849239499274179,"base_score":2.3978952727983707,"endowment":2.3978952727983707,"self_citation_contribution":0.3596842909197557,"citation_network_contribution":0.4252396590076622,"self_endowment_contribution":0.3596842909197557,"citer_contribution":0.4252396590076622,"corpus_percentile":null,"corpus_rank":null,"citation_count":10,"citer_count":9,"citers_with_citation_signal":6,"citers_with_endowment":6,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1678549,"name":"Jack D Sobel","orcid":null,"position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"Syndromic Treatment of Women With Vulvovaginal Symptoms in the United States: A Call to Action!","abstract":"(See the Major Article by Hillier et al on pages 1538–43.) The syndromic approach to diagnosis and treatment is still widely prevalent and practiced in many undeveloped countries. Study after study indicates the failure and inadequacies of this method, but it is justifiably used only when specific diagnostic methods and qualified personnel are not available due to a variety of socioeconomic reasons. Surely, the syndromic approach is not utilized in the United States, given the plethora of both qualified practitioners and specific diagnostic tests. Not surprisingly, the more specialized the practitioner, the lower the likelihood that empiricism in diagnostic and therapeutic decision-making will be operative. There is probably no clinical area where the syndromic approach is more evident than when women present to practitioners with vulvovaginal symptoms. Unfortunately, evidence of prevailing empiricism in the United States is provided in the well-designed and -implemented study conducted by Hillier et al [1] across 8 University of Pittsburgh Medical Center–affiliated clinics. Although not surprising to vaginitis specialists, the findings are still shocking and reveal the prevailing “bad deal” women receive from trusted practitioners. Principally, inexpensive and uncomplicated rapid point-of-care tests were infrequently performed. Even more disturbing was that in a community practice setting, where vulvovaginal complaints—including discharge—were extremely common, almost half the symptomatic women received inappropriate treatment. The consequences of inappropriate treatment are not trivial. Apart from the cost, symptoms continue, return visits are inevitable, and trust is lost. Underdiagnoses and consequent inappropriate therapy allow the persistence of clinical manifestations with the continued risks of numerous complications, including the risk of human immunodeficiency virus transmission. The consequences of overdiagnoses and inappropriate treatment are greater and less well recognized, including excessive, often unnecessary antibiotic use for nonexistent bacterial infections contributing to iatrogenic, symptomatic vaginal candidiasis, as well as the risk of fluconazole resistance. The lack of commitment to achieving diagnostic accuracy is, in part, indifference to the consequences of inappropriate therapy, but also to a lack of awareness of those consequences. Is there a tendency to trivialize these nonfatal symptoms? This conclusion is fortified by the author’s personal experience in interacting with obstetrics-gynecology residents in educational, often university-based service clinics and repeatedly observing an unacceptable attitude inherited from teaching faculty. Unfortunately, adequate standards of acceptable diagnostic skills are not demanded by certification boards. Nevertheless, further information is needed regarding barriers to clinicians appropriately diagnosing and managing vaginal symptoms in all scenarios. The Pittsburgh study adds further evidence to the now irrefutable conclusion that practitioners do not and will not ever use currently available, inexpensive point-of-care tests, including pH measurements and microscopies. Sadly, long before they enter clinical practice, practitioners are never trained to use these simple tests. Subsequently, they encounter conditions in practice which prevent the utilization and implementation of such tests. Unfortunately, reality demands that we finally move on. Targeting and teaching residents to use these tests does not now and will never work. Firstly, we need to convince practitioners that guessing is not acceptable or fair to our patients and that correct diagnoses are essential. Then, the next step is to persuade practitioners that a diagnosis is possible with the availability of a plethora of commercially available molecular tests that utilize amplification methods and next-generation sequencing. Some—but not all—such tests are already approved by the Food and Drug Administration, but most are likely reliable, although some delay in obtaining results is currently inevitable. Such a delay is likely to decrease dramatically as tests are performed in the local environment. Diagnostic tests provide practitioners with valuable data to allow enhanced therapy, as well as avoid unnecessary treatment. If time restraints prevent practitioners from obtaining diagnostic swabs then, as Hillier et al [1] suggest, perhaps self-obtained vaginal swabs could facilitate diagnoses. Of course, simply demonstrating the presence or absence of pathogens is not sufficient to provide or guarantee therapeutic excellence. As is apparent in the Hillier et al [1] study, vulvovaginal symptoms are frequently not caused by Candida, bacterial vaginosis, or trichomonas microorganisms. More information on yet-unrecognized pathogens is needed, as is an understanding of noninfectious vulvovaginitis. Even when microbial pathogens are identified in symptomatic women, the practitioner needs to establish causality: that is, assurance that the pathogen is actually causing the vaginitis symptoms, including vaginal discharge. As we struggle with student and resident education, is teaching “causation” feasible? Getting practitioners to seek the correct diagnoses and avoid empiricism must be the next, if not urgent, challenge. As utilized in the United States, the prevailing syndromic approach as applied to women with vulvovaginal symptoms is no more than guessing and is no longer tolerable. In addition, without waiting for practitioners to implement these new, achievable standards, women need to actively demand a higher standard from practitioners. Financial support. J. D. S. declares no funding sources. Potential conflicts of interest. The author: No reported conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.","is_dataset_classified":null,"base_score":2.3978952727983707,"endowment":2.3978952727983707,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"32350527","pmcid":null,"openalex_id":"https://openalex.org/W3022218379","authors":[],"funders":[],"total_grants":0,"fwci":0.9134,"citation_percentile":0.70482666,"influential_citations":0,"citation_trend":[{"year":2021,"count":1},{"year":2022,"count":3},{"year":2023,"count":3},{"year":2024,"count":2},{"year":2026,"count":1}],"oa_status":"closed","license":"https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model","oa_locations":[{"url":"http://academic.oup.com/cid/advance-article-pdf/doi/10.1093/cid/ciaa267/33138000/ciaa267.pdf","host_type":"publisher"},{"url":"http://academic.oup.com/cid/article-pdf/72/9/1544/37792745/ciaa267.pdf","host_type":"publisher"},{"url":"https://doi.org/10.1093/cid/ciaa267","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/32350527","host_type":"repository"}],"fields_of_study":["Reproductive tract infections research","Pelvic floor disorders treatments","Sexual function and dysfunction studies","Female","Humans","Postmenopause","Syndrome","United States","Vaginal Discharge"],"mesh_terms":["Female","Humans","Syndrome","United States","Postmenopause","Vaginal Discharge"],"keywords":["Call to action","Action (physics)","Medicine","Psychology","Family medicine","Advertising","Business"],"sdg_mappings":[{"sdg_number":0,"sdg_label":"Gender equality"}],"linked_datasets":[],"clinical_trials":[],"software_tools":[],"database_accessions":[],"source":"live","citation_network_status":"fetched"},"created_at":"2026-08-09T02:10:55.508420Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}