Online Letters to the Editor
Tinidazole for Treatment of Trichomonas Vaginalis
TO THE EDITOR: Drs. Owen and Clenney presented a nicely organized review of the management of vaginitis in their American Family Physician article.1 They mention tinidazole (Tindamax) for the treatment of Trichomonas vaginalis. This drug has been approved by the U.S. Food and Drug Administration and is now available in the United States for the treatment of T. vaginalis. It is given in a single 2-g oral dose, similar to metronidazole (Flagyl), both of which interact with alcohol. Side effects of the two drugs are similar. Tinidazole is pregnancy category C and is contraindicated in women who are in the first trimester. Metronidazole is pregnancy category B. Tinidazole is considerably more expensive than generic metronidazole but may be effective in patients with metronidazole-resistant Trichomonas.2
In the discussion of diagnostic criteria for bacterial vaginosis, the authors1 correctly quote the Amsel criteria. The presence of a fishy odor would certainly be a positive whiff test, but the traditional way to do the whiff test is to check for a fishy odor after adding a few drops of 10 percent potassium hydroxide to the vaginal secretions.3 This raises the pH and causes a release of aromatic amines by the anaerobes, resulting in a distinctive amine, or fishy odor, that may not be evident on initial examination.
REFERENCES
1. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician 2004;70:2125-32.
2. Tinidazole (Tindamax)—a new anti-protozoal drug. Med Lett Drugs Ther 2004;46:70-2.
3. Eschenbach DA, Hillier S, Critchlow C, Stevens C, DeRouen T, Holmes KK. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol 1988;158:819-28.
Suggest Vegetarian Diet to Patients with Dysmenorrhea
to the editor: I was pleased to see lifestyle modification, specifically a low-fat vegetarian diet,1 mentioned as a treatment option for dysmenorrhea in the American Family Physician article, “Dysmenorrhea,”2 by Dr. French. Although this intervention is classified as “B” on the “Strength of Recommendation” scale (as compared with the “A” rating for nonsteroidal anti-inflammatory drugs [NSAIDs]), there are safety advantages to starting with a nonpharmacologic intervention when available. If a nonpharmacologic treatment corrects the underlying cause of symptoms, it may obviate the need for pharmacologic treatment of the resultant symptoms. At a minimum, changes in behavior can be recommended concomitantly with pharmaceutical intervention.
A vegetarian diet has numerous advantages. For example, a companion publication3 to the diet study1 cited above showed that premenopausal women eating a vegetarian diet for five weeks had a significant reduction in low-density lipoprotein (LDL) cholesterol (16.9 percent, P <.001) and a 2.5-kg (5.5 lb) weight loss (P <.001), as compared with women on their customary diet and receiving a placebo supplement. This degree of LDL lowering was 11 times greater than what would be expected by weight loss alone.4
A diet change also is typically free of adverse effects. In contrast, cholesterol-lowering drugs, antihypertensives, NSAIDs, and multiple other drug classes are associated with significant risks. Specifically, many patients taking NSAIDs exceed the maximum recommended dosage because of their over-the-counter availability.
There are two apparent biologic mechanisms by which dietary changes influence dysmenorrhea. First, vegetarian diets appear to raise blood concentrations of sex-hormone binding globulin, which binds and inactivates estrogens.5 Second, estrogen and progesterone stimulate the endometrium, which is the source of the prostaglandins that are thought to induce ischemia and uterine muscle contraction6 and the painful symptoms of dysmenorrhea. Through dietary modulation of estrogen and resultant prostaglandin production, the need for NSAIDs could be minimized.
Many patients would accept, or even prefer, a recommendation of a vegetarian diet over a drug prescription if it was offered by physicians for dysmenorrhea and for conditions such as hypertension, hyperlipidemia, and diabetes. It remains to be seen whether such a diet may be beneficial in reducing risk for other conditions linked to estrogen activity, such as uterine fibroids or hormone-dependent cancers. Much evidence exists to support nutritional interventions as a therapeutic modality for common diseases, and more will continue to emerge to the extent we employ such modalities in the clinical setting.
REFERENCES
1. Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol 2000;95:245-50.
2. French L. Dysmenorrhea. Am Fam Physician 2005;71:285-91.
3. Barnard ND, Scialli AR, Bertron P, Hurlock D, Edmonds K, Talev L. Effectiveness of a low-fat vegetarian diet in altering serum lipids in healthy premenopausal women. Am J Cardiol 2000;85:969-72.
4. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr 1992;56:320-8.
5. Adlercreutz H. Western diet and Western diseases: some hormonal and biochemical mechanisms and associations. Scand J Clin Lab Invest Suppl 1990;201:3-23.
6. Benedetto C. Eicosanoids in primary dysmenorrhea, endometriosis and menstrual migraine. Gynecol Endocrinol 1989;3:71-94.
in reply: Dr. Jaster makes some very good points about the health benefits of a vegetarian diet in addition to its potential to favorably impact dysmenorrhea. I agree that it is appropriate to emphasize this diet when discussing therapeutic options with young women. However, it remains to be seen whether such a major lifestyle change is acceptable and sustainable for many young women. Counseling for a balanced vegetarian diet also is essential. My anecdotal experience is that young women may decide to stop eating meat without eating a balanced diet rich in vegetables and vegetable proteins. Protein requirements are not difficult to cover if dairy products are consumed regularly; otherwise, it does take some planning. Another consideration for young women who pursue vegetarian diets is the risk for iron deficiency anemia. Again, it takes some planning to get enough iron from vegetable sources.
Send letters to Kenny Lin, M.D., Contributing Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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