Analysis of Vaginal Candidiasis Prevalence Among Bangladeshi Women in Relation to Menstrual Hygiene and Other Risk Factors: A Cross-Sectional Study

Vaginal candidiasis, which is an infection of the female reproductive system, continues to be a leading risk factor of morbidity, which negatively impact the physical and mental health of women worldwide. Despite widespread awareness, vaginal candidiasis is still seen as a minor health issue in many impoverished nations like Bangladesh. This study aimed to examine and evaluate the prevalence of vaginal candidiasis and its association with menstrual hygiene and other risk factors among reproductive-aged women by cross-sectional study. In this research study 37.30% of women (91 out of 244 patients) tested positive with vaginal candidiasis. From this study is was found that patients in their early and peak reproductive years are more susceptible to illness. The highest prevalence was seen among the participants who aged between 15-34 years (33%), which followed by 20.9% patients are from 35-44 years age group and 70.3% of patients were married. The most common symptoms patients faced in this study are irritation and swelling near genital area (24.8%), unusual vaginal discharge (22.6%), itching near genital area (20.4%), pain or burning sensation during urination (16.8%) and painful intercourse (11.7%). Besides, risk factors that caused the disease in patients to be found are, poor menstrual hygiene (35%), unsafe intercourse (38%), non-cotton and unclean undergarment (18.6%), use of over the counter antibiotic (14.2%), diabetes (8%), infected sexual partner (3.4%), STD (3%) and menopause (0.8%). Another major part of the study is to know about the relation between menstrual hygiene and vaginal candidiasis. About 33% of the women use cloth and another 33% use both sanitary napkin and cloth as an absorbent. It is also observed that 74.7% women change the absorbent only about 1-2 times per day. Though, Vaginal Candidiasis is a type of mild infection for most the cases still it needs to be given importance as it can cause troublesome and serious complications such as recurrent infection, candidemia etc.


Introduction
One of the characteristics that sets living things apart from inanimate things is their capacity for reproduction.Reproduction is a process where parent organism give birth to offspring's that are genetically or biologically similar to themselves.Reproduction is the most important feature of earth by which the existence of species continues.Two types of reproduction can be seen.They are, asexual reproduction and sexual Reproduction.As being part of animal kingdom human reproduce sexually.In sexual reproduction 2 parents are required.This is a process where a new unique life forms are made by the combination of hereditary data from two people of various genders.The hereditary data or genetic information is stored on chromosomes which is situated inside the nucleus of particular sex cells called gametes.The male gamete is called sperm whereas the female gamete is called egg or ovum.In the process of sexual reproduction these two gametes fused together a process named as fertilization to create a zygote which then produce embryo.In fallopian tubes fertilization takes place.Fallopian tube connects the ovaries to the uterus.The female reproductive system is a sensitive and intricate part of the female body.Infections, injuries, and other issues (including some chronic ones) can be avoided if one takes the right precautions.Reproductive health is a subset of sexual and reproductive rights which focuses on an individual's overall well-being as it relates to reproduction at every age.
The World Health Organization (WHO) defines reproductive health as a "condition of full physical, mental, and social well-being in all aspects relevant to the reproductive system and its activities and processes, which goes beyond the simple absence of sickness or infirmity".It is crucial to take good care of female reproductive organs in order to prevent a number of painful and uncomfortable reproductive illnesses and the spread of STDs.Keep one's reproductive system in good shape is guarantee to a healthy sexual life.Likewise, it's important for the growth of healthy kids.Women's reproductive health problems are directly responsible for the bulk of the world's 1.3 million female deaths per year.
Infections of the reproductive system are being recognized as a major worldwide health issue that affects not only individuals but also their loved ones and community.Negative effects such as infertility, ectopic pregnancy, persistent pelvic discomfort, miscarriage, and a higher risk of HIV transmission are all possible results.Since many female reproductive tract infections are asymptomatic or have vague symptoms, women bear a significant share of the burden of untreated RTIs.Despite the fact that RTIs afflict women in both developing and developed nations, the infections and their consequences are an especially pressing public health concern in places with limited access to healthcare.A

Introduction
As the name implies, vaginal candidiasis (VC) is an infection caused by yeast or fungi in the genital area (Okonkwo & Umeanaeto, 2011).The vagina and vulvar tissues become inflamed and itchy due to the vaginal yeast infection, which is caused by a Candida overgrowth.This disease is also known as vulvovaginal candidiasis or candidal vaginitis or vaginal thrush.
Vaginal Candidiasis develops when Candida organisms gradually invade the mucosal lining of the vagina and trigger an inflammatory reaction.
Polymorphonuclear cells and macrophages are often the predominant inflammatory cells.Inflammatory alterations in the vaginal and vulvar epithelium are the direct result of a fungal infection, most often caused by Candida albicans, and are responsible for the development of vaginal candidiasis.Candida is considered part of a woman's natural flora, and many women have it without any noticeable symptoms (Patel et al, 2003).Thus, discomfort, itch, dysuria, or inflammation are necessary for a diagnosis of vaginal candidiasis in addition to the presence of Candida in the vagina/vulva.Glycogen, a substrate on which C. albicans thrives, (Sustr et al., 2020) is produced in the vaginal lining because of oestrogen hormone.
Symptoms tend to emerge in the second part of the menstruation, when progesterone levels are naturally higher.Female genital candidiasis, or vaginal candidiasis, is less prevalent in postmenopausal women of all ages because of the decline in estrogen levels.
A typical vaginal flora includes a mix of bacteria and yeast.Some strains of bacteria, termed lactobacilli, benefit from the presence of estrogen and flourish as a result.These microorganisms protect health by eliminating pathogens in the vaginal environment.Yeast infections are caused by the fungus Candida, which can grow out of control if the body's natural defenses are overwhelmed.This disease often develops when the vaginal pH becomes unbalanced.

Organism Causing the Disease
Candida is a kind of yeast that is responsible for the vast majority of all fungal infections.Overgrowth of Candida in vagina cause vaginal candidiasis.Large, spherical, white or cream (albicans means "whitish" in Latin) colonies with a yeasty odor develop when Candida is cultivated in the lab on agar plates at room temperature.The most common form of candidiasis is caused by Candida albicans, a species that is normally found as a commensal in the human flora and which can be found in the skin, intestines, and urinary system.Depending on the circumstances, C. albicans may develop as yeast, pseudo hyphae, or genuine hyphae in vitro and in vivo, making it a human opportunist pathogen (Al-Ahmadey & Mohamed, 2014).

Scientific Classification:
Using of Contraceptive Devices: Yeast infections could be more common for women who use intrauterine devices (IUDs), diaphragms, or vaginal sponges.Vaginal Candidiasis are not often caused by spermicides; however, some women may have genital discomfort.

Literature review
Vaginal candidiasis is extremely common, with 13 million cases reported each year in the United States alone (Horowitz, 1991).As many as 1.4 million women seek medical attention each year for vaginal candidiasis (Benedict et al., 2018).Vaginal infections caused by Candida are second only to bacterial vaginosis in frequency of occurrence (Diadhiou et al., 2019).Seventy-five percent of women, according to surveys, get thrush or yeast infection in their vagina at some point in their lives (Sobel, 2007).Forty to fifty percent of those women will have another episode (Sobel, 2014).Only around 8 percent of women get chronic candidal vulvovaginitis.The distinction between colonization and infection is crucial since half of infected women will have a second episode and 5-8% will have recurrent vulvovaginal candidosis (RVVC) if they are not treated.When Vulvovaginal Candidosis occurs more than four times in a year, it is considered recurrent.According to recent statistics, over 138 million women globally experience RVVC each year, and another 372 million experience it over the course of their lives (Denning et al., 2018).The peak incidence years for RVVC are between the ages of 19 and 35, and a recent study found that the prevalence of RVVC increases to 9 percent in those over the age of 50 (Blostein et al., 2017).As a result of a deficiency in the normally protective immune response to a prior Candida infection, women with RVVC are more susceptible to recurrent candidiasis (Fidel & Sobel, 1996).
Candida albicans accounts for over 90% of cases of vaginal candidiasis, whereas other species of Candida account for the remaining 10% (Abdullahi Nasir et al., 2015).For the rest, C. glabrata and C. tropicalis are the most frequent species (Felix et al., 2018).Women of all ages are susceptible to Candida spp.infections, although they are most common in those who are pregnant (nearly 24%) and in those who are not (around 17%) (Al-akeel et al., 2013).The most prevalent cause of VVC is Candida albicans, however widespread use of azole antifungal medicines may have led to a change in vaginal colonization and the selection of more naturally fungal species, such as Candida glabrata (Mathema et al., 2001).
It must be noted that specific epidemiological statistics on this illness process are not yet accessible.The reason behind this is, over-thecounter remedies for candidal vulvovaginitis are widely available, therefore many people with the condition probably don't seek medical attention.Also, a diagnosis is based on both clinical and non-clinical evaluations.Because of this, epidemiological reports based on culture alone exaggerate disease, since 10% of women with positive candidal cultures don't have any symptoms.
In a study, women's ages ranged from 18 to 55 years, 81% of the women experienced irritation, 74% faced itching and 87% reported about discharge.It has been observed that the prevalence of vaginal candidiasis infection is 9% when using a direct test, and 29% when using a Mixture Culture.Candida albicans was found to be the most common yeast isolate among these patients, accounting for 28 of the total cases (70%).It is also demonstrated that there is no statistically significant associations between vulvovaginal candidiasis and several demographic variables, including age, education, symptoms, contraception, marital status, and diabetes mellitus.However, no statistically significant association between vulvovaginal candidiasis and employment status was discovered (Reza Faraji et al., 2012).
A research study conducted in Nigeria found that female students in their early and prime reproductive years were more susceptible to infection, a peak incidence of vaginal candidiasis (32.3%) between the ages of 22 and 26, the ages of 17 and 21 had the next highest prevalence (29.4%), while the lowest (5.7%) prevalence among those aged 27 to 31years.From the study it was also observed that the highest occurrence which is 37.5% was linked to prolonged use of broad-spectrum antibiotics (Mbim E.et al., 2017).Another study, it is depicted that people with weakened immune systems were more likely to contract this infection.(Winston DJ, 1995).
This study demonstrated about the importance of screening for VC along with other vaginal infections as vaginal candidiasis (VC) is common

Laboratory Tests
In both hospitals microscopic tests were done.Specimens were obtained by swabbing the vagina and were placed on a glass slide with a few drops of saline, then covered with a coverslip.Yeast cells were looked under microscope under 400x magnification.Vaginal swabs were mixed with another drop of saline solution and 10% KOH, which dissolves patient's cells and yeast can be seen easily in slides.

Statistical Analysis
For the data analysis Microsoft Excel and IBM SPSS is used.Descriptive statistics were used to assess the data gathered for this study.

Result
Data was summarized and analyzed after it was collected from patient interviews and pathology lab reports.The purpose of this data analysis is to determine the prevalence of various characteristics among patients and to compare these frequencies among patients with different factors.

Distribution of patients' with the disease
The Distribution of Patients' after diagnosis of the disease is shown in the following frequency table The total number of participants was 244.Among them 91 women were positive for Vaginal Candidiasis.Hence, they were selected as the study participants.Patients who were tested negative for Vaginal Candidiasis were excluded from the study.Out of 91 patients 64 were married and 27 were unmarried.The result shows that prevalence of Vaginal Candidiasis is higher in married women (70.3%), rather than unmarried patients (29.7%).The highest number of VC patients, 31, i.e. 34.1% had completed their higher secondary education.Second highest number of VC patients have completed secondary education.Surprisingly about one-fourth percent of patients (25.3%) have completed Graduation.Also, the number of primary pass patients is 7 (7.7%), which is the second lowest value seen.
In this study, prevalence of vaginal candidiasis was observed among various socio-demographic factors such as age, marital status, education and social status.The frequency table shows that 68 patients (74.7%) change their absorbent only 1-2 times in a day, which is the highest number of patients.
Only 23.1% patient change their absorbent 3-4 times. 2 patients who were in menopause during the study were placed in the category of none.
The distribution of vaginal candidiasis patient based on their risk factors can be categorized in the following table: The frequency table of factors that caused Vaginal Candidiasis among patients shows that the factor that caused the disease most is use of  The use of over the counter antibiotic is the reason which caused the disease in most married women (30.8%), poor menstrual hygiene affected 16.5% women, 12.1% used non-cotton and unclean undergarments, 2.2% had unsafe intercourse and 8.8% have diabetes.From the table it can be said that non-cotton and unclean undergarment mainly caused the disease in unmarried women (11%), 8.8% got it by using over the counter antibiotic, 3.3% have diabetes and 6.6% from poor menstrual hygiene.
The following table shows the analysis of education of Vaginal Candidiasis patients based on factors: From the cross-table analysis of education and causative factor, it has been found that all participants from no educational background used over the counter antibiotic which caused the disease.Moreover, participants from primary educational background, 3.3% used over the counter antibiotic, 2.2% wear non-cotton and unclean undergarments and in 2.2% poor menstrual hygiene is seen.Additionally, among secondary education grouped women, 9.9% used over the counter antibiotic, 8.8% wear non-cotton and unclean undergarments, in 7.7% poor menstrual hygiene is seen and 2.2% have diabetes.Furthermore, those with a higher secondary education, 13.2% used over the counter antibiotic, 4.4% wear non-cotton and unclean undergarments, in 11% poor menstrual hygiene is seen and 5.5% have diabetes.Then, individuals with a graduation background 8.8% used over the counter antibiotic, 7.7% wear non-cotton and unclean undergarments, in 2.2% poor menstrual hygiene is seen, 2.2% had unsafe intercourse and 4.4% have diabetes.
The following table shows the social status of Vaginal Candidiasis patients based on factors: From the cross table, it has been observed that, in upper class participants 5.5% have diabetes and 1.1% used over the counter antibiotic as a causative factor for the disease.Moreover, participants from middle class, 12.1% patients had use of over the counter antibiotic, 12.1% use non-cotton and unclean undergarment, 9.9% had poor menstrual hygiene, 3.3 have diabetes and 2.2% had unsafe intercourse as a causative factor for the disease.Additionally, among lower middle-class grouped women 18.7% patients had use of over the counter antibiotic, 8.8% use non-cotton and unclean undergarment, 11% had poor menstrual hygiene, 3.3% have diabetes which is a causative factor for the disease.
Furthermore, those from poor background, 7.7% patients had use of over the counter antibiotic, 2.2% use non-cotton and unclean undergarment, 2.2% had poor menstrual hygiene which is a causative factor for the disease.From the cross-table analysis, it has been observed that, women aged between 15 to 24 years, 15.4% had unusual vaginal discharge, 11% had pain or burning sensation during urination, 4.4% had itching near the genital area, 1.1% had painful menstruation and 1.1% had painful intercourse as symptoms.Moreover, women aged between 25 to 34 years, 16.5% had pain or burning sensation during urination, 11% had unusual vaginal discharge, 2.2% had itching near the genital area, 2.2% had painful intercourse and 1.1% had irritation or swelling near the genital area as symptoms.Then, women aged between 35 to 44 years, 13.2% had pain or burning sensation during urination, 4.4% had unusual vaginal discharge, 2.2% had itching near the genital area, and 1.1% had nausea and vomiting as symptoms.Furthermore, women aged between 45 to 54 years, 8.8% had pain or burning sensation during urination and 2.2% had unusual vaginal discharge as symptoms.
Women aged between 55 to 64 years, 1.1% had unusual vaginal discharge, 1.1% had pain or burning sensation during urination as symptoms.
The cross-table analysis of the marital status of Vaginal Candidiasis patients based on symptoms: The cross-table analysis shows that the symptoms varied between married and unmarried patients, here 39.6% married women experienced pain or burning sensation during urination where as 11% unmarried women had this symptom.Similarly, unusual vaginal discharge was present on 20.9% married patients and 13.2% unmarried patients.Moreover, 4.4% from each married and unmarried woman faced itching near the genital area.Also, irritation, sore and swelling near the genital area was present in 1% married women and only married patients (3.3%) experienced painful intercourse and nausea and vomiting (1.1%) as a symptom.Besides, only unmarried patients (1.1%) experience painful menstruation as a symptom.
The analysis of education of Vaginal Candidiasis patients based on symptoms is shown below: From the cross-table analysis of education and causative factor, it has been found that all participants from no educational background all of them had pain and burning sensation during urination (4.4%).Moreover, participants from primary educational background, 4.4% had pain and burning sensation during urination, 2.2% had unusual vaginal discharge and 1.1% had nausea and vomiting as a symptom.Additionally, among secondary education grouped women, 12.1% had pain and burning sensation during urination, 9.9% had unusual vaginal discharge, 2.2% had painful intercourse and 4.4% had itching near genital area as a symptom.Furthermore, those with a higher secondary education, 19.8% had pain and burning sensation during urination, 11% had unusual vaginal discharge, 1.1% had painful menstruation, 1.1%had irritation and swelling near the genital area and 1.1% had itching near genital area as a symptom.Then, individuals with a graduation background, 9.9% had pain and burning sensation during urination, 11% had unusual vaginal discharge, 1.1% had painful intercourse and 3.3% had itching near genital area as a symptom.
The analysis of social status of Vaginal Candidiasis patients based on symptoms: From the cross-table analysis, it has been observed that, women aged between 15 to 24 years, 14.3% faced recurrent infection, 13.2% faced skin infection, 3.3% had candidemia and 2.2% did not face any complications.Moreover, women aged between 25 to 34 years, 19.8% faced recurrent infection, 6.6% faced skin infection, 2.2% had candidemia and 4.4% did not face any complications.Then, women aged between 35 to 44 years, 5.5% faced recurrent infection, 7.7% faced skin infection, 3.3% had candidemia and 4.4% did not face any complications.
Furthermore, women aged between 45 to 54 years, 4.4% faced recurrent infection, 4.4% faced skin infection, 1.1% had candidemia and 1.1% did not face any complications.Women aged between 55 to 64 years, 1.1% faced recurrent infection, 1.1% faced skin infection as complications.Cross-table analysis of marital status of Vaginal Candidiasis patients based on complications: From the cross-table analysis of education and causative factor, it has been found that all participants from no educational background had recurrent infection (2.2%) and candidemia (2.2%) as complication.Moreover, participants from primary educational background, 3.3% had recurrent infection, 3.3% had skin infection and 1.1% had candidemia.Additionally, among secondary education grouped women, 11% had recurrent infection, 13.2% had skin infection, 1.1% had candidemia and 3.3% showed no complication.Furthermore, those with a higher secondary education, 13.2% had recurrent infection, 12.1% had skin infection, 4.4% had candidemia and 4.4% showed no complications.
Then, individuals with a graduation background, 15.4% had recurrent infection, 4.4% had skin infection, 1.1% had candidemia and 4.4%   From the cross table it has been observed that women who use cloth as absorbent, 17.6% had over the counter antibiotic, 3.3% have diabetes, 3.3% use non-cotton and unclean undergarment and 8.8% women use non-cotton and unclean undergarment.Among the patients who use sanitary napkin, using of non-cotton and unclean undergarment caused the disease in most (11%) also poor menstrual hygiene is the second highest factor which caused the disease (7.7%).Using over counter antibiotic caused the disease in most women who use both type of absorbent (15.4%).Cross-table analysis of symptoms of Vaginal Candidiasis patients based on type of absorbents: Among women who use cloth as absorbent, 24.2% had pain or burning sensation during urination, 5.5% had unusual vaginal discharge, 1.1% faced nausea and vomiting, 1.1% faced painful intercourse and itching near the genital area is seen in 1.1%.Moreover, patients who use sanitary napkin, among them 13.2% showed unusual vaginal discharge, 12.1% had pain and burning sensation during urination, 3.3% faced itching near genital area, 2.2% had painful intercourse and 1.1% had painful menstruation which showed as symptom.Additionally, patients who employ both absorbent types, 14.3% had unusual vaginal discharge, 13.2% had pain and burning sensation while urinating, 4.4% faced itching and 1.1% faced irritation or swelling near genital area.Furthermore, participants those do not use any type of absorbents, among them, 1.1% faced pain or burning sensation during urination and 1.1% had unusual vaginal discharge.Cross-   From the cross-table analysis of education and absorbent change rate per day, it has been found that, all participants from no educational background change absorbent only 1-2 times a day.Moreover, participants from primary educational background, all of the 7.7% change absorbent 1-2 times per day.Additionally, among secondary education grouped women, 25.3% change absorbent 1-2 times a day and 3.3% change it 3-4 times.Furthermore, those with a higher secondary education, 20.9% change absorbents 1-2 a day and 12.1% change it 3-4 times.Then, individuals with a graduation background most of them change absorbent material 1-2 times a day (16.5%) and others (7.7%) change 3-4 times a day.From the analysis it can be said that most of the participants change absorbents 1-2 times a day.Cross-

Conclusion
Sexual and Reproductive Health and Rights (SRHR) for women still remains as a taboo in our country.This study was conducted over the course of almost a year with the purpose of evaluating the incidence and various risk factors of Vaginal Candidiasis among Bangladeshi women.
This research shows that 37.30% of women (91 out of 244 patients) tested had vaginal candidiasis whereas Brande et al. (1996) assessment shows yeast infections affect around 75% women at some point in their lives.The highest prevalence was among the patients who aged between 15-34 years (33%) followed by 20.9% patients were between 35-44 age group, 11% are from 45-54 years range; and 2.2% within the age range of 55-64 years.Vaginal candidiasis is more prevalent among reproductive-age women than among those of any other age (Müller, J., 1993) and (Emeribe, A. U. et al, 2015).
From the result it was found that prevalence of Vaginal Candidiasis is higher in married women (70.3%), rather than unmarried patients (29.7%).According to a study conducted by Dou et al. (2015), the researchers found out that married women were more likely to experience Vaginal Candidiasis between the ages of 15 and 34 years old had the highest rates of vaginal candidiasis, and 70.3% of all patients were married.
Menstrual hygiene is one the most important factor that can cause vaginal candidiasis among women.This study showed that among cloth, sanitary napkin and mixture of both, most patients use cloth and both cloth and sanitary napkin as an absorbent.33% use cloth and 33% use both types.Also, from this study it was found that, 74.7% women change absorbents 1-2 times a day and only 23.1% change it 3-4 times per day.From these results it can be said that most of the patients have poor menstrual hygiene.Women who used reusable sanitary napkins had a higher risk of contracting Candida than those who used disposable ones, according to research by Torondel et al. (2018).The most common symptoms patients faced in this study are irritation and swelling near genital area (24.8%), unusual vaginal discharge (22.6%), itching near genital area (20.4%), pain or burning sensation during urination (16.8%) and painful intercourse (11.7%).Patients with positive cultures may experience symptoms such as vaginal itching either with or without vaginal discharge (50%), vaginal discharge alone (30%), or no symptoms at all (20%) found by (Oriel et al., 1972).
Pregnancy, hormone replacement, poorly managed diabetic mellitus, immunosuppression, the use of antibiotics and glucocorticoids, and genetic predispositions are all hypothesized to increase the risk of infection in the host (Sobel, 2007).From this study risk factors that caused the disease in patients to be found are, poor menstrual hygiene (35%), unsafe intercourse (38%), non-cotton and unclean undergarment (18.6%), use of over the counter antibiotic (14.2%), diabetes (8%), infected sexual partner (3.4%), STD (3%) and menopause (0.8%).The increased prevalence of vulvovaginal candidiasis (VVC) in diabetic women compared to nondiabetic women has led researchers to speculate that diabetes mellitus (DM) may be a risk factor for the development of vulvovaginal candidiasis VVC (Gonçalves et al., 2015).For women with diabetes, the prevalence of VVC is estimated to be 32.5-67.5%,while for those without diabetes it is 11-23% (Goswami et al., 2006).
Inadequate hygiene, for instance, can serve as a reservoir for Candida spores in the digestive tract, leading to an elevated spore burden (Ferrer, 2000).As reported by Ahmad and Khan (2009) in India, the prevalence of VVC was 36 percent greater among women who reported having poor genital cleanliness compared to those who reported having good personal hygiene.According to a Brazilian research, the prevalence of VVC is 65.8 percent greater in women who wear tight and/or synthetic underwear compared to those who don't (39.1 percent) (Holanda et al., 2007).Antibiotic-treated women had a higher risk of developing VVC than antibiotic-naive women, supported by the studies in India (Ahmad & Khan, 2009), Greece (Grigoriou et al., 2006), and Italy (Spinillo et al., 1995(Spinillo et al., , 1999)).The main complication participants faced in this study is recurrent infection.Only around 5% of women may get four or more vaginal yeast infections in a single year, a medical term known as Recurrent Vaginal Candidiasis (RVC).
To overcome the problems with Vaginal Candidiasis, education about reproductive health, reproductive health diseases and infections, and menstrual hygiene needs to be taught in schools so that from a young age, female can learn and know how to have a healthy life style.Also, proper training for screening methods and distinguishing between different RTI can be arranged in hospitals.Government should lower the price of menstrual products and provide WASH facilities for women.Professionals in the medical field should highlight the need of regular examinations and practicing good reproductive hygiene in preventing these diseases.Preventing drug-resistant Candida strains, reducing the incidence of RVVC, and taking into account potential medication interactions will all be more pressing concerns in the years to come.One of the most difficult tasks will be to stop fungal infections from developing resistance to antimycotic drugs.

Statements and Declarations
Patients and/or their legal guardians gave their verbal agreement to participate in the study (in the case of minors).They were given thorough background on the research and its purpose.The responders' names were also concealed.

_____
No funding is required.This is a Msc thesis, part of academic degree.Biotechnology program.

Table 1 .
Distribution of patients' with disease

Table 2 .
Frequency Table Distribution of

Table 3 .
Frequency Table Distribution of Type of

Table 4 .
Distribution of Duration of Menstrual Bleeding Per

Table 5 .
The vaginal candidiasis patient based on type of absorbent patient uses during menstruation is distributed as follows: Distribution of Type of Absorbent The distribution of vaginal candidiasis patient based on absorbent change rate of patient per day is exposed as follows:Absorbent Change Rate in a Day Frequency Percentage (%)

Table 6 .
Frequency Table Distribution of Absorbent ChangeRate of Patient Per Day Among VC Patients

Table 7 .
Frequency Table Distribution of Factors Causing the

Table 8 .
Cross -table analysis of age of Vaginal Candidiasis patients based on factors that caused the disease Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF9/32 over the Counter Antibiotic (39.6%).The second highest risk factor is menstrual hygiene or Non-Cotton and Unclean Undergarment (23.1%).The following table shows the age of Vaginal Candidiasis patients based on factors that caused the disease: Among the participants aged between 15-24, most the patients got this disease due to use of over the counter antibiotic (11%) and use of noncotton and unclean undergarments (11%), 8.8% had the disease due to poor menstrual hygiene and 2.2% had diabetes.Use of over the counter antibiotic is the main factor which caused the disease in most of the women, 12.1% in age range of 25-34, 9.9% in 35-44 age, 5.55% in 45-54 age and only 1.1% in participants age between 55-64.The next factor which caused the disease in most participants is poor menstrual hygiene and non-cotton and unclean undergarment.Where poor menstrual hygiene is seen on 6.6% (in 25-34), 5.5% (35-44), 2.2% (45-54) participants of different age group.Diabetes is the third causing factor, it caused disease in the women who aged between 25-34 (4.4%), total 4 person have diabetes age ranged between 35-54.The following table shows the analysis of marital status of Vaginal Candidiasis patients based on factors:

Table 12 .
Frequency Table Distribution of Symptoms Displayed by the The Distribution of Vaginal Candidiasis Patient Based on Their Symptoms (Multiple answer) is distributed as following: Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF13/32 A single patient can have more than one symptom present for Vaginal Candidiasis.Majority of the patient had unusual vaginal discharge (50.5%), whereas 34.1% of patients complained about having unusual vaginal discharge and 8.8% of patients having itching near the genital.The cross -table analysis of age of Vaginal Candidiasis patients based on symptoms can be classified as folowing:

Table 13 .
Cross -table analysis of age of Vaginal Candidiasis patients based on symptoms

Symptoms Social Status Upper Class Middle Class Lower Middle Class Poor Total Pain or Burning Sensation during Urination
From the cross table, it has been observed that, in upper class participants, 3.3% showed unusual vaginal discharge, 2.2% had pain or burning during urination and 1.1% had painful intercourse as symptom.Moreover, participants from middle class, 19.8% showed pain or burning sensation during urination, 12.1% had unusual vaginal discharge, 5.5% had itching near genital area and 2.2% had painful intercourse as symptoms.Additionally, among lower middle-class grouped women, 19.8% had pain or burning sensation during urination, 16.5% had unusual vaginal discharge, 3.3% had itching near the genital area, 1.1% had irritation, sore and swelling near the genital area and 1.1% had painful intercourse as symptoms.Furthermore, those from poor background, 8.8% had pain or burning sensation during urination, 2.2% had unusual vaginal discharge and 1.1% had nausea and vomiting as symptom.The following table shows the distribution of Vaginal Candidiasis Patient Based on Their Complications:

Table 17 .
Frequency Table Distribution ofComplications Faced by the Patient Among VC PatientsSurprisingly 45.1% patient had vaginal candidiasis for multiple times which is known as recurrent infection and the second most common complication the patient faced was skin infection (33%).The Cross -table analysis of age of Vaginal Candidiasis patients based on complications: Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF17/32

Table 18 .
Cross -table analysis of age of Vaginal Candidiasis patients based on complications

Table 19 .
Cross-table analysis of marital status of Vaginal Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF18/32Thiscross-table analysis shows that the variation of complications between married and unmarried women.Here, 31.9% of married women faced recurrent infection where 13.2% of unmarried women faced it.Moreover, 20.9% of married participants and 12.1% of unmarried participants got skin infection.9.9% of married and 2.2% of unmarried women faced no complications where as 7.7% married participants and 2.2% unmarried participants got candidemia as a complication.Cross-table analysis of education of Vaginal Candidiasis patients based on complications:

Table 20 .
Cross-table analysis of education of Vaginal Candidiasis patients based on complications

Social Status Total Upper Class Middle Class Lower Middle Class Poor Recurrent of
Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF19/32 showed no complications.Cross-table analysis of social status of Vaginal Candidiasis patients based on complications:

Table 21 .
Cross-table analysis of social status of Vaginal Candidiasis patients based on complicationsFrom the cross table, it has been observed that, in upper class participants, 2.2% had recurrent infection, 1.1% had candidemia, 1.1% had skin infection and 2.2% showed no complications at all.Moreover, participants from middle class, 17.6% had recurrent infection, 4.4% had candidemia, 12.1% had skin infection and 5.5% showed no complications at all.Additionally, among lower middle-class grouped women, 19.8% had recurrent infection, 1.1% had candidemia, 16.5% had skin infection and 4.4% showed no complications at all.Furthermore, those from poor background, 5.5% had recurrent infection, 3.3% had candidemia, 3.3% had skin infection as complications the association of Types of Absorbent with different factors is classified as following table.Age (

Table 22 .
Cross-table analysis of Age and Types of Absorbent use sanitary napkin as absorbent (15.4%), rest of them use cloth (6.6%) and both type of absorbent is used by 11%.13.2% women aged between 35 to 44 years use cloth, 15.4% use sanitary napkin and 5.5% use both type of absorbent.Women aged between 45 to 54 years mostly use cloth (7.7%), the second highest percent of women use both type of absorbent (2.2%) and rest of 1.1% use sanitary napkin.Women of ages between 55 to 64 do not use any type of absorbent as they have menopause.Cross-table analysis of Marital Status of Vaginal

Table 23 .
Cross-table analysis of Marital Status of Vaginal Candidiasis patients based on type of absorbentsIn married women about 28.6% use cloth, 17.6% use sanitary napkin, 22% use both type and 2.2% do not use any type of absorbent.In between unmarried women 4.4% use cloth, 14.3% use sanitary napkin, 11% use both type of absorbent.Married women mostly use cloth and unmarried women use sanitary napkin mostly.Cross-table analysis of education of Vaginal Candidiasis patients based on type of absorbents: Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF20/32Candidiasispatients based on type of absorbents:

Table 24 .
Cross-table analysis of education of Vaginal Candidiasis patients based on type of absorbentsFrom the cross table between educational background and type of absorbent, various type of result can be seen.Patients with no educational background (4.4%) and who completed primary education (7.7%) use cloth as an absorbent.Among patient with secondary education 9.9% use cloth, 6.6% use sanitary napkin and 16.5% uses both type of absorbent.17.6% patient who are from graduation background use sanitary napkin which is a healthy practice.Women with higher secondary background use both type absorbent (16.5%) most.Cross-table analysis of social status of Vaginal Candidiasis patients based on type of absorbents:

Type of Absorbent Socio-economic Background Total Upper Class Middle Class Lower Middle Class Poor
From the cross table, it has been observed that upper class women only use sanitary napkin (6.6%) and women from poor social class only use cloth (12.1%).Various type of result can be seen for middle class and lower middle-class people.Women from middle class background mostly use sanitary napkin (23.1%), others use cloth (5.5%) and 8.8% use both types.Lower middle-class backgrounded women use both type mostly (24.2%).5 Cross-table analysis of factors of Vaginal Candidiasis patients based on type of absorbents:

Table 26 .
Cross-table analysis of factors of Vaginal Candidiasis patients based on type of absorbents

Complications Type of Absorbent Total Cloth Sanitary Napkin Both None Recurrent of Infection
table analysis of complications of Vaginal Candidiasis patients based on type of absorbents:

Table 28 .
Cross-table analysis of complications of Vaginal Candidiasis patients based on type of absorbentsFrom the cross-table analysis, it is observed that women who use cloth as absorbent, among them 14.3% faced skin infection, 13.2% had recurrent infection, 4.4% had candidemia and only 1.1% faced no complications at all.Moreover, patients who use sanitary napkin, 15.4% faced recurrent infection, 12.1% had skin infection, 4.4% had candidemia and 6.6% faced no complications at all.Additionally, patients who employ both absorbent types, 15.4% patients faced recurrent infection, 12.1% had skin infection, 1.1% faced candidemia and 4.4% patients had no complications.Furthermore, participants those do not use any type of absorbents, among them, 1.1% faced recurrent infection and Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF23/32 1.1% had skin infection.Association of Absorbent Change Rate Per Day with different factors:

Table 29 .
Cross -table analysis of age of VaginalCandidiasis patients based on absorbent change rate per day From the cross-table analysis of age of VC patients based on absorbent change rate, it can be seen from participants aged between 15 to 24, most of them change the absorbent rate 1-2 times per day (30.8%),rest of the participants (2.2%) change absorbent 3-4 times in a day.In all of the age range most of the participants change their absorbent only 1-2 times, result in 18.7% in25-34, 14.3% in 35-44 and 11% on womenage ranged between 45-54.Among participants who change absorbent 3-4 times a day, 14.3% are from 25-34 age and 6.6% are from 35-44 age range.Women aged among 55 to 64 years age do not need to change absorbent as they have menopause.Cross-table analysis of marital status of Vaginal Candidiasis patients based on absorbent change rate

Table 30 .
Cross-table analysis of marital status of Vaginal Candidiasis

Table 31 .
Cross-table analysis of education of Vaginal Candidiasis patients based on absorbents change rate

Change Rate in a Day Socio-economic Background Total Upper Class Middle Class Lower Middle Class Poor 1-2 times
table analysis of social status of Vaginal Candidiasis patients based on absorbent change rate in a day:

Table 32 .
Cross-table analysis of social status of Vaginal Candidiasis patients based on absorbent change

Factors Absorbent Change Rate in a Day Total 1-2 times 3-4 times None Use of over the Counter Antibiotic
From the cross-table analysis of symptoms of VC patients based on absorbent change rate, it can be seen that, patients who change absorbent 1-2 times a day, 29.7% used over the counter antibiotic, 20.9% use non-cotton and unclean undergarment, 16.5% had poor menstrual hygiene, 1.1% had unsafe intercourse and 6.6% have diabetes which caused the disease.Additionally, VC patients who change absorbent 3-4 times per day, among them 8.8% used over the counter antibiotic, 2.2% use non-cotton and unclean undergarment, 6.6% had poor menstrual hygiene, 1.1% had unsafe intercourse and 4.4% have diabetes as causative factor.Moreover, participants who do not change absorbent, 1.1% used over the counter antibiotic, 1.1% have diabetes which caused the disease.Cross-table analysis of symptoms of Vaginal Candidiasis patients based on absorbent change rate:

Table 34 .
Cross-table analysis of symptoms of Vaginal Candidiasis patients based on near genital area, 2.2% had painful intercourse and 1.1% faced nausea and vomiting.Additionally, VC patients who change absorbent 3-4 times per day, among them 11% had pain or burning sensation while urinating, 8.8% showed unusual vaginal discharge, 1.1% had painful intercourse, 1.1% had painful menstruation and 1.1% faced irritation and swelling near genital area as symptom.Moreover, participants who do not change absorbent, 1.1% had pain or burning sensation while urinating, 1.1% showed unusual vaginal discharge as symptoms.Cross-table Qeios, CC-BY 4.0 • Article, March 12, 2024 Qeios ID: 5CORDF • https://doi.org/10.32388/5CORDF26/32 analysis of complications of Vaginal Candidiasis patients based on absorbent change rate:

Table 35 : Cross-table analysis of complications of Vaginal Candidiasis patients based on absorbent change rate
From the cross-table analysis of complications of VC patients based on absorbent change rate, it can be seen that, patients who change absorbent 1-2 times a day faced recurrent infection most (35.2%), from rest 23.1% had skin infection, 7.7% had candidemia and 8.8% faced no complication at all.Additionally, VC patients who change absorbent 3-4 times per day, among them, 8.8% faced recurrent infection and another 8.85 had skin infection, 2.2% had candidemia and 3.3% had no complication.Moreover, participants who do not change absorbent, 1.1% faced skin infection and 1.1% faced recurrent infection.