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Lack of Evidence for Sexual Transmission

of Genital Candida Species Among Women
Who Have Sex With Women
A Mixed Methods Study
Christina A Muzny, Charles A Rivers, Cameron J Parker, Leandro A Mena, Erika L Austin,
Jane R Schwebke
Sex Transm Infect. 2014;90(2):165-170.

Abstract and Introduction

Abstract
Objective. The contribution of sexual transmission to genital Candida infection remains
unclear. This study sought to investigate whether sexual behaviours were associated with the
presence of genital Candida species among a cohort of women who have sex with women
(WSW) in addition to determining the genetic concordance of genital Candida spp. among
WSW in sexual partnerships.
Methods. WSW 18 years of age presenting to the Mississippi State Department of Health
STD Clinic during 20092010 completed a sexual behaviour survey. Culture of vaginal fluid
was performed for Candida spp. identification; associations with participant characteristics
were determined using logistic regression analysis. Random amplified polymorphic DNA
(RAPD) PCR was performed on DNA extracted from yeast cultures of WSW in sexual
partnerships in which both partners had isolates of Candida spp. identified and among a set of
age/sexual behaviour matched controls. RAPD genetic fingerprints were evaluated by
hierarchical cluster analysis for concordance.
Results. Genital Candida spp. were isolated in 105/196 (53.6%) of women: 13/105 (12.4%)
had symptomatic vulvovaginal candidiasis while 92/105 (87.6%) had asymptomatic vaginal
colonisation. Bisexual identity, sex with women and men during the past 12 months and
numbers of male sexual partners during the past 12 months were the only significant
predictors of genital Candida spp. in bivariate analysis. 13 pairs of WSW in sexual
partnerships in which both partners had genital Candida spp. and 11 WSW with genital
Candida spp. not in sexual partnerships were identified. Candida spp. RAPD banding
patterns were discordant for all isolates among WSW within partnerships and in controls.

Conclusions. This study found no evidence supporting sexual transmission of genital

Candida spp. between women.
Introduction
Vulvovaginal candidiasis (VVC) is a common vaginal infection affecting up to 75% of
women.[1] It is second only to bacterial vaginosis (BV) in frequency of vaginal infections.[2,3]
Studies have shown that VVC may be more common among African-Americans.[4] Candida
albicans is the yeast species most likely to cause VVC, although it may be caused by C
glabrata, C tropicalis and rarely other Candida spp. [5] In addition to causing symptomatic
disease, Candida spp. also colonise the vagina in approximately 1520% of asymptomatic
women.[1,5]
The contribution of sexual transmission to genital Candida spp. and VVC remains unclear.[1]
Epidemiological studies have shown that VVC is associated with increased frequency of
vaginal sex,[6] receptive orogenital sex[4,6] and increased numbers of heterosexual partners.[7]
Molecular genetic evidence also suggests that colonisation with specific strains of C albicans
predispose women to the development of VVC; strains with similar molecular signatures
have been found in both men and women with active genital yeast infections.[8] Correlation of
candidal infection between sexual partners in heterosexual relationships has been observed,[9]
and studies using genotype comparison techniques have suggested that genital C albicans
isolates may be sexually transmitted.[8] Nevertheless, conflicting evidence exists regarding the
treatment of male partners of women with recurrent VVC.[10,11] Studies among heterosexual
partnerships have not provided evidence beyond indirect correlation that yeast can be
sexually transmitted.[9]
Recently, the plausibility of sexual transmission of genital Candida spp. among women who
have sex with women (WSW) has been suggested in a study showing increasing odds of
VVC (either symptomatic or asymptomatic) with greater numbers of female partners.[12]
Additional epidemiological data and partner studies are needed to clarify whether genital
Candida spp. can be sexually transmitted between women. The objectives of this study were
to investigate whether sexual behaviours were associated with the presence of genital
Candida spp. among a cohort of WSW in addition to determining the genetic concordance of
Candida spp. among WSW in sexual partnerships in which both partners had a positive yeast
culture.

Methods
Clinical Procedures and Specimen Collection
This study was approved by the Institutional Review Boards at the University of Mississippi
Medical Center (UMMC), the Mississippi State Department of Health (MSDH) and the
University of Alabama at Birmingham (UAB). African-American WSW aged 18 years
presenting to the MSDH STD Clinic in Jackson, MS, between February 2009 and October
2010 and participating in a study of STI prevalence and risk behaviours among WSW[13]
provided specimens. A written survey on sociodemographics, sexual history, sexual
behaviour characteristics and sexual partnership characteristics was completed by
participants, as previously reported,[13,14] followed by a standardised pelvic exam with
collection of vaginal fluid for pH measurement, saline microscopy, potassium hydroxide
evaluation and Gram stain (three of four Amsel's criteria[15] were necessary for the clinical

diagnosis of BV). During the exam, a polyester swab was used to collect secretions from the
posterior vaginal fornix in order to perform yeast culture. Vaginal fluid was also collected for
Trichomonas vaginalis InPouch culture, Chlamydia trachomatis and Neisseria gonorrhoeae
testing using the Aptima Combo 2 assay, and Mycoplasma genitalium testing using a
modified Aptima assay, as previously reported.[13,14] Serum was collected for syphilis and HIV
testing, as previously reported.[13]
Yeast Culture
The yeast collection swab was used to inoculate a liquid culture (brain heart infusion (BHI)
broth supplemented with penicillin and streptomycin) within 24 h postcollection. Positive
cultures were archived by cryopreservation in BHI with 10% glycerol. A cryopreserved
archive of each positive liquid culture at UMMC was subsequently sent to UAB for formal
speciation. A sample of the cryopreserved specimen was cultivated on Sabouraud Dextrose
Agar (BD Diagnostics, Sparks, Maryland, USA) supplemented with gentamicin and
CHROMagar Candida (supplemented with chloramphenicol; DRG International, Springfield,
New Jersey, USA). Colony morphology, colour and germ tube growth characteristics were
noted. Colonies were phenotypically categorised by gross observation and microscopic
growth characteristics on corn meal agar (BD Diagnostics), and yeast species were confirmed
by the API 20C AUX biochemical panel (Biomrieux, Durham, North Carolina, USA).
DNA Extraction
We identified WSW in active sexual partnerships with another woman in the study in which
both women had a positive yeast culture; a representative of each matching yeast colony
phenotype observed in culture from each partner was selected for DNA extraction. An
additional group of WSW not in active sexual partnerships with another woman in the study
was randomly matched to the women in sexual partnerships, selected via distribution
frequencies by age and sexual contact with men. This control group was selected to provide a
sampling of the potential genetic diversity of all yeast isolates within the entire cohort of
women.
A 35-day-old colony was picked from positive yeast culture plates and suspended in sterile
phosphate buffered saline, pH 7.5. The suspension was washed and centrifuged to remove the
supernatant. The pellet was resuspended in a sterile cocktail of Tris/EDTA/sodium chloride
(TEN) buffer (pH 7.5) and 50 mM dithiothreitol (DTT). Zymolase (G-Biosciences, St. Louis,
Missouri, USA) was added to a final concentration of 0.15 U/L and incubated at 37C for 1
h. The spheroplasts were pelleted and digest supernatant was removed by centrifugation. The
spheroplast pellet was resuspended in 100 mM DTT containing 0.075 mAU/L of Proteinase
K (Qiagen, Valencia, California, USA) and incubated at 70C for 10 min. DNA from the
treated spheroplasts was extracted using Generation Capture Column chromatography
(Qiagen). The concentration and purity of the DNA was determined by NanoDrop (Thermo
Scientific, Wilmington, Delaware, USA). All colony isolate DNAs were adjusted to a
working concentration of 5 ng/L.
RAPD Analysis
A total of 25 ng of template DNA was used per random amplified polymorphic DNA (RAPD)
reaction. The Illustra Ready-To-Go RAPD Analysis Beads kit (GE Healthcare Biosciences,
Pittsburgh, Pennsylvania, USA) was used according to manufacturer's instructions. The kit

contains six RAPD primers; these primers are specifically designed to be arbitrary and used
alone in each reaction. Amplicons were electrophoresed in 1X Tris/Acetate/EDTA (pH 8.3)
on 2% agarose gels prestained with ethidium bromide at 45 V for 16 h at 4C. The resultant
gels were imaged, and the nucleotide base-pair sizes of the banding patterns produced from
the RAPD amplicons were estimated by comparison to a molecular weight DNA ladder (HiLo DNA Marker, Minnesota Molecular, Minneapolis, Minnesota, USA) using Quantity One
software V.4.6.9 (Bio-Rad, Hercules, California, USA). DNA band sizes were entered into a
spreadsheet for cluster analysis with SPSS V.21 (IBM Corporation, Armonk, New York,
USA).
Statistical Analysis
Statistical analysis for epidemiological data was conducted using Stata/IC V.12.1 (College
Station, Texas, USA). Percentage distributions were calculated for all categorical variables;
continuous variables were categorised for ease of interpretation. Unadjusted associations
between each demographic/behavioural factor and the presence of genital Candida spp. were
examined using logistic regression analysis.

Results
One hundred and ninety-six African-American WSW were enrolled; age ranged from 18 to
40 with the majority of women being <25 (mean=24.5, SD=5.0). Of these 196 women, 111
(58%) reported sex with women only during the previous 12 months, while 80 (42%)
reported sex with both women and men (WSWM) during this time frame. Other demographic
and behavioural characteristics of this sample have been presented previously.[13] In total,
105/196 (53.6%) women were found to have genital Candida spp. isolated by culture: 13/105
(12.4%) were diagnosed with symptomatic VVC while 92/105 (87.6%) had asymptomatic
vaginal colonisation. Characteristics of study participants, stratified by the presence of genital
Candida spp., are presented in .
Table 1. Characteristics of study participants and association with genital
N (%)

Candida spp.present N
(%)

Unadjusted OR (95%
CI)

p Value

1824

107
(54)

57 (53)

0.9 (0.5 to1.7)

0.92

2545

89 (46) 48 (54)

Characteristic
Age group

Reference

Sexual partners, past 12 months

Women and
men
Women only

80 (42) 57 (71)

3.5 (1.9 to 6.5)

111
(58)

Reference

46 (41)

0.01

Sexual identity
Bisexual

59 (33) 39 (66)

2.3 (1.2 to 4.5)

0.01

Lesbian

119
(67)

54 (45)

Reference

59 (58)

1.4 (0.8 to 2.5)

Douched, past 30 days

Yes

102
(53)

No

91 (47) 45 (49)

0.24

Reference

Tobacco use, past 30 days

Yes

103
(55)

No

85 (45) 45 (53)

56 (54)

1.0 (0.6 to1.89)

0.84

Reference

Alcohol use, past 30 days

Yes

124
(66)

No

65 (34) 32 (49)

71 (57)

1.3 (0.7 to 2.5)

0.29

Reference

Age at first sex with female partner

18

156
(89)

>18

20 (11) 12 (60)

80 (51)

0.6 (0.3 to 1.2)

0.20

Reference

No. of female partners, lifetime

>1

165
(89)

20 (11) 13 (65)

86 (53)

0.6 (0.2 to 1.5)

0.28

Reference

No. of female partners, past 12 months

>1

97 (51) 58 (60)

1.6 (0.9 to 2.9)

93 (49) 44 (47)

Reference

Yes

174
(89)

1.4 (0.6 to 3.5)

No

22 (11) 10 (45)

0.08

Sex with men, ever

95 (55)

0.81

Reference

Age at first sex with male partner

18

132
(96)

70 (53)

0.3 (0.0 to 2.6)

>18

5 (4)

4 (80)

Reference

0.26

No. of male partners, lifetime

>1

117

65 (56)

1.1 (0.6 to 2.1)

0.71

(71)
1

27 (16) 11 (41)

Reference

None

22 (13) 10 (45)

0.7 (0.3 to 2.0)

0.56
0.91

No. of male partners, past 12 months

>1

43 (25) 29 (67)

0.9 (0.4 to 2.2)

30 (17) 23 (76)

Reference

None

96 (57) 37 (38)

0.3 (0.1 to 0.6)

0.01
0.28

Receptive analingus by female or male partners, ever

Yes

97 (65) 50 (52)

0.7 (0.3 to 1.4)

No

51 (35) 31 (61)

Reference

Vaginal penetration by female partners, ever

Yes

106
(62)

No

65 (38) 33 (51)

55 (52)

1.0 (0.6 to 1.9)

0.88

Reference

Shared use of vaginally inserted sex toys with female partners, ever
Yes

60 (34) 37 (62)

1.4 (0.7 to 2.7)

No

117
(66)

Reference

62 (53)

0.27

Condom use on sex toys with female partner

Consistent

67 (45) 35 (52)

0.7 (0.4 to 1.4)

Inconsistent

83 (55) 50 (60)

Reference

0.32

Barrier use at sexual exposure sites, past 3 months

Consistent

39 (21) 17 (44)

0.5 (0.3 to 1.1)

Inconsistent

150
(79)

Reference

87 (58)

0.11

Barrier use at LSE with female partner

Yes

19 (10) 8 (42)

0.6 (0.2 to 1.5)

No

170
(90)

Reference

96 (56)

0.23

Diagnosis of bacterial vaginosis

Yes

96 (49) 53 (51)

1.1 (0.6 to 1.9)

No

100
(51)

Reference

Diagnosis of any STI

52 (49)

0.65

Positive

58 (30) 32 (55)

1.1 (0.6 to 2.0)

Negative

137
(70)

Reference

73 (53)

0.09

*Numbers in subgroups may not total to sums in columns due to missing data on selected
variables.
Diagnosis of BV based on three of four Amsel's criteria.
Any STI includes Trichomonas vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis,
Mycoplasma genitalium, syphilis and HIV.
BV, bacterial vaginosis; LSE, last sexual encounter.
Few variables were associated with the presence of genital Candida spp. Women claiming
bisexual identity were more likely to have Candida spp. than lesbian-identified women (OR
2.3; 95% CI 1.2 to 4.5; p=.01). Likewise, women who reported both female and male partners
over the past 12 months were significantly more likely to have Candida spp. (OR 3.5, 95%
CI 1.9 to 6.4; p=.01) than women who reported female partners only. The number of male
partners over the past 12 months was also associated with Candida spp., although there was
no difference associated with having 1 vs >1 male partners. None of the other sexual partner
or sexual behaviour variables were associated with the presence of genital Candida spp. nor
was diagnosis with BV or any STI.
In total, 104/105 women had archived yeast cultures available. demonstrates the prevalence
of various Candida spp. among these yeast cultures. Also, 71/104 (68.3%) women had only
one yeast phenotype; the remaining participants (n=33; 31.7%) had two (26.0%), three
(3.8%) or four (1.9%) distinct yeast phenotypes isolated in culture. C albicans represented
83.7% of all yeast isolates, C tropicalis 17.3%, C parapsilosis 19.2%, C glabrata 11.5%, C
kruseii 5.8% and C lusitaniae 1.9%.
Table 2. Prevalence of genital
Candida spp.

% prevalence*

C albicans

83.7

Phenotype 1

56.7

Phenotype 2

25.0

Phenotype 3

1.9

C tropicalis

17.3

Phenotype 1

11.5

Phenotype 2

5.8

C parapsilosis

19.2

C glabrata

11.5

C kruseii

5.8

C lusitaniae

1.9

*Percentages total greater than 100% because 31.7% of the clinical specimens contained
multiple Candida spp.
Among the 104 WSW with positive genital yeast cultures available for further study, 25
women (in a total of 13 sexual partnerships) were identified in which both female partners
had a yeast isolate grown in culture; 11 of these sexual partnerships did not share a common
partner while 2 shared a common partner who was also enrolled in the study. Four
partnerships consisted of exclusive WSW during the past 12 months, one partnership of
WSW reporting sex with both women and men (WSWM) during this time frame and eight
partnerships a mixture of both WSW and WSWM. RAPD patterns using three of the six
available primers in the kit resolved discordance in 66% of the Candida spp. phenotypes
between female partners (Figure 1), that is, the yeast strains between partners were not
genetically identical. The initial number of RAPD reactions was 75; three reactions with three
unique primers for the 25 women in sexual partnerships. Because several women had
multiple yeast isolates, cross-tab testing was performed on all identical yeast phenotypes
shared between members of the partnerships; this approach incurred an additional 27 RAPD
reactions, which resolved three of the six potential phenotype combinations using the original
primer set. The remaining three combinations of yeast isolates required the use of the
additional three primers in the RAPD kit not used in the original RAPD amplifications.
Overall, RAPD banding patterns were discordant in all 13 WSW sexual partnerships.

Figure 1.

Example random amplified polymorphic DNA (RAPD) amplicon pattern of yeast isolates in
matched partners of women who have sex with women (WSW) sexual partnerships. The
RAPD amplicon patterns of nine WSW sexual partnerships (partnerships 412), each with a
respective yeast isolate, are presented. The molecular weight DNA markers are denoted by an
'L', with 2, 1 and 0.5 marking the positions of the 2000 base pair (bp), 1000 bp and 500 bp
positions. For this RAPD pattern, among all banding patterns, four basic patterns were
observed; however, with the exception of partnership 9, all patterns were discordant between
partners. The RAPD patterns of three to six unique primer reactions were combined for
hierarchical cluster investigation.
A dendogram plot was produced using hierarchical clustering analysis of the amplicon
patterns produced by the series of RAPD reactions (Figure 2). Candida spp. fell into two
distinct clusters. Cluster 1 contained C albicans and C tropicalis while cluster 2 contained C
parapsilosis, C glabrata and C krusei. Of note, 7 of the 13 female sexual partnerships were a
C albicans/C parapsilosis pairing. C albicans was shared between the remaining six female
sexual partnerships, with some individuals having >1 C albicans strain, as defined by
phenotype and genotype results.

Figure 2.

Hierarchical cluster dendogram of random amplified polymorphic DNA (RAPD) amplicon

patterns of yeast isolates between matched women who have sex with women (WSW)
subjects in matched partnerships. The hierarchical distribution of yeast RAPD fingerprints
from 13 WSW sexual partnerships is presented in this dendogram. Partnerships are visually
indentified by the overlay of linked coloured circles consistent with denoted couples on the xaxis; samples denoted as 'Couple 0' were not in active sexual partnerships with other women
in the study. Two major clusters are identified. Cluster 1 contains C albicans (circles with
green) and C tropicalis (circles with blue). Cluster 2 contains C parapsilosis (circles with
pink), C glabrata (circles with purple), C krusei (circle with yellow) and a C tropicalis
substrain (circle with dark blue). Many partners had more than one clinical yeast phenotype
isolate, as denoted by the multicoloured circle. Matching yeast phenotypes between partners

with multiple isolates was cross-checked by RAPD for concordance. All yeast isolates were
observed to be discordant between partners and among all isolates.

Discussion
This mixed methods study found no evidence (epidemiological or laboratory-based)
supporting sexual transmission of genital Candida spp. between women. This is in contrast to
findings from a previous study that found increasing odds of VVC (either asymptomatic or
symptomatic) among WSW with greater numbers of female partners during the previous year.
[12]
Bisexual identity, sex with women and men during the past 12 months and numbers of
male partners during the past 12 months were the only significant predictors of genital
Candida spp. in this study. We found no associations between numbers of female partners
(both lifetime and past 12 months) nor sexual practices with female partners (ie, vaginal
penetration by female partners, shared use of vaginally inserted sex toys with female partners,
inconsistent condom use on sex toys with female partners, etc.) and the presence of genital
Candida spp. In addition, RAPD banding patterns were discordant for all yeast isolates
among WSW within sexual partnerships in which both partners had a positive yeast culture as
well as in a group of controls.
It has been hypothesised that penile-vaginal intercourse might facilitate the movement of
Candida spp. into the vagina and result in minor local trauma that creates conditions suitable
for tissue invasion.[16 17] An association between frequency of heterosexual intercourse and
symptomatic attacks of VVC has formed the basis of this hypothesis.[16 17] In addition,
epidemiological data suggest that orogenital and anogenital contact may also transmit yeast.
[4,6,18]
Prior studies using molecular techniques to genotype strains of Candida spp. among
women with VVC and their male partners have shown genetic similarities, further supporting
the hypothesis of sexual transmission.[8,1922] With regards to WSW, it is hypothesised that
sexual activities such as orogenital sex and the sharing of sex toys could facilitate crossinfection of Candida spp., leading to vaginal colonisation and subsequent development of
infection.[12] Indeed, sexual exchange of infected vaginal fluid has been found to be a possible
mechanism for the acquisition of BV among WSW.[23,24] However, taking into account the
results of our study and the fact that genital Candida spp. can gain access to the vaginal
lumen from the adjacent perianal area,[3] it may be that the pathogenesis of BV and vaginal
yeast infections is different among WSW, that is, WSW may acquire genital Candida spp.
endogenously while BV is acquired exogenously from infected female partner(s). Thus, it
remains unknown whether Candida spp. are truly sexually transmitted or whether sexual
activities only potentiate Candida spp. colonisation while additional factors (ie, use of
antibiotics, etc.) influence development of infection.[3]
To our knowledge, this is the first study using RAPD to perform genotypic characterisation of
genital Candida spp. among WSW in sexual partnerships in which both partners had a
positive yeast culture. We found no evidence of genetic concordance of yeast isolates among
WSW in sexual partnerships. In keeping with the hypothesis mentioned above and our
results, it may be that femalefemale sexual practices do not sufficiently facilitate the
movement of Candida spp. into the vagina nor induce enough local trauma to create
conditions suitable for tissue invasion of yeast. Alternatively, it could also be that repeated
sexual exposures to female partner(s), similar to those that predispose WSW to a higher risk
of colonisation of Gardnerella vaginalis [25] and other BV-associated bacteria, are necessary to
facilitate the transfer of yeast between women. Unfortunately, we did not have data available
with regards to the frequency of sexual activities WSW in sexual partnerships participated in

with their female partners. It is also important to note that several women in the partnerships
were also having sex with men at the time of enrolment; how this influenced their genital
yeast isolates is unknown as we did not have their male partners available for testing.
Therefore, further research is necessary to confirm the results of our study.
Although not a primary objective, it should be noted that this is the first study detailing the
prevalence of genital Candida spp. among a cohort of African-American WSW. Our observed
prevalence (53.6%) was much higher than that seen in prior studies of premenopausal women
(1520%)[3] and Caucasian WSW (18.4%).[12] Potential explanations could be that all women
in this study were of African-American race (a genetic factor that may predispose to
colonisation or vaginitis with yeast),[4] constituted a high-risk STD clinic population
frequently diagnosed with BV/STIs and may have recently taken antibiotics or had additional
risk factors predisposing them to yeast colonisation/VVC.[1] Unfortunately, we did not collect
the latter information and can only speculate that this may have contributed. Interestingly, in
a study of 338 predominately African-American women at an STD clinic in Birmingham,
Alabama, USA, the prevalence of yeast detected by wet prep/culture was also high at 39.1%.
[26]

We also found that multiple species and mixed subspecies of Candida can be isolated from
the vaginal vault. The four species associated with VVC in the USA (C albicans, C tropicalis,
C glabrata and C parapsilosis)[1] were observed in this population. However, while three of
the four species were found in similar rates to those described in the literature,[27] C
parapsilosis was present at an unusually higher rate (19.2%). The prevalence of C
parapsilosis in the USA is estimated to be 1.7% nationally and 1.8% in the South.[27] Potential
reasons for this deviation from the national prevalence of C parapsilosis among women in
this study are unknown. Of note, a higher prevalence of C parapsilosis (12%) has been
observed in a study of Costa Rican sex workers with or without VVC.[28] In this study, the use
of miconazole 4 times a year, for treatment or prophylaxis, was significantly associated with
drug resistance among the C parapsilosis isolates. Given the recent increase in non-C
albicans-associated VVC,[29] perhaps attributed to the overuse/abuse of over-the-counter
(OTC) antifungals,[30] one could hypothesise that the increased prevalence of C parapsilosis
observed in our study could be related to behavioural factors such as overuse of this type of
medication. However, we did not have detailed behavioural information available with
regards to frequency of OTC vaginal antifungal use to see whether such a correlation existed.
This study has several limitations. First, the relatively small sample size of African-American
WSW presenting to an urban STD clinic in Jackson, MS, limits the generalisability of our
results. Second, as this was a pilot study, we were unable to collect data on receptive oral sex
with female partners or data on other specific sexual practices with female partners, which
could have an association with the presence of genital Candida spp. In addition, although
RAPD is a powerful molecular technique that allows for the investigation of genetic
information without prior knowledge of the target organism's genome, it has several
weaknesses. Template DNA may be contaminated from other sources. In addition, if RAPD
conditions are not optimised and consistent from test to test, results may not be reproducible.
Resultant banding patterns may be difficult to interpret in number, intensity and position to a
standard. Nevertheless, RAPD can be a valuable tool under controlled and well-characterised
settings such as those used in our current and prior[14] studies.
In conclusion, in contrast to previous studies of BV, this study found no evidence of sexual
transmission of genital Candida spp. between women. More research is needed to better

understand the contribution of sexual transmission to genital Candida spp. isolates and VVC
among WSW.
Key Messages

The contribution of sexual transmission to genital Candida spp. and vulvovaginal

candidiasis remains unclear.

In contrast to previous studies of bacterial vaginosis, this study found no evidence

(epidemiological or laboratory-based) supporting sexual transmission of genital
Candida spp. between women.

The overall prevalence of genital Candida spp. in this study (53.6%) was much higher
than that noted in prior studies of premenopausal women (1520%).

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Acknowledgements
The authors would like to thank Heather King, Tina Barnes and the Crossroads STD Clinic
nursing staff for their assistance in recruiting and enrolling patients for this study. In addition,
the authors would like to thank the laboratory personnel of John Cleary, PharmD, and Edwin
Swiatlo, MD, PhD, for archiving the yeast isolates at the University of Mississippi Medical
Center prior to transfer to the University of Alabama at Birmingham. The authors would also
like to thank Edwin Swiatlo, MD, PhD, for helpful discussions regarding manuscript
preparation. CAM is supported in part by a Developmental Award from the American
Sexually Transmitted Diseases Association.
Contributors
CAM, CAR, LAM and JRS were responsible for conception and design.CAM, CAR, CJP and
LAM were responsible for acquisition of data.CAM, CAR, ELA and JRS were responsible
for analysis or interpretation of data.CAM, CAR and ELA were responsible for drafting of
the manuscript.CAM, CAR, CJP, ELA and JRS were responsible for revising the manuscript
for intellectual content. All authors were responsible for the final version of the manuscript to
be published.
Funding
Data from this study were presented in part at the 20th Biennial Conference of the
International Society of Sexually Transmitted Diseases Research in Vienna, Austria, on July
16, 2013; abstract# P1.036.
Competing Interests
None.

Ethics Approval
University of Mississippi Medical Center, Mississippi State Department of Health, University
of Alabama at Birmingham.
Provenance and Peer Review
Not commissioned; externally peer reviewed.
Sex Transm Infect. 2014;90(2):165-170. 2014 BMJ Publishing Group