So what's with the horse with the blinders, you ask?  Judging from the title, you were expecting vaginas--not horses, right?  Well, the whole point of my last two entries is that the typical allergist is so hung up on the respiratory tract, he/she cannot look either left or right--just straight ahead, plodding down the 'ol dusty respiratory tract:  from the tip of the nose down to the last terminal bronchiole.  And in the process of "putting on the blinders", he/she morphs into an "asthma doctor"--and becomes less of an allergist than he/she was meant to be.  And frankly the horse is to be given more credit than allergists--at least the horse had the blinders put on him by someone else.  In our case, we put the blinders on ourselves.  As an "asthma doctor" we offer less services than a pulmonologist (no bronchoscopy, no respiratory tract skills for handling the severely ill asthmatic) and we offer less services as a "compleate" allergist.  In truth, by trying to be both things, we really become neither. 

Succinctly put:  if we want to be better allergists, then we better "take off the blinders" and look around at all the mucosal membranes in the body.  In my last journal entry, I promised that "I'll give one more simple example of an area we have shamelessly ignored, to the detriment of our practices and our patients..."  And so begins The Vagina Monologues

By the way, this really is a mini-series, so set your DVR's for the next 3 installments:

• Part I--The Vagina as an immunologically reactive organ
• Part II-Clinical relevance in everyday practice
• Part III Suggestions for the future

Part I--The Vagina as an immunologically reactive organ

As I mentioned in my earlier comments, curiosity is essential in being a better allergist.  And why should we be curious about an organ that is so far removed from the respiratory tract?  In truth, there are some compelling reasons:

• The human vaginal basal lamina contains macrophages, lymphocytes, eosinophils, plasma cells, and mast cells
• IgE antibodies specific to C. albicans, seminal fluid components, pollen and spermicides have been identified in vaginal fluids of women with recurrent vaginitis
• Prostaglandin E2 can be found in the vagina
• Vaginal smears containing eosinophils have been observed
• IgE induced histamine release is a potent inducer of prostaglandin E2 from macrophages, which in turn suppresses the cell-mediated immune response necessary to keep Candida albicans in check
• At least eight publications from 1920 to 1995 describe allergic vulvovaginitis due to pollens
• In 1978 Haddad (Perspect Allergy 1:2-3, 1978)reported the case of a woman allergic to walnuts who developed anaphylaxis on one occasion after intercourse with her husband, who had ingested walnuts prior to coitus.  Seminal fluid revealed the presence of walnut protein. 
• In 1988 Witkin identified Candida albicans specific IgE in vaginal washes 
• There are in the literature at least five case reports and five open studies, including 177 patients suffering from recurrent vaginal candidiasis who had been prescribed Candida albicans allergen immunotherapy.  These women had positive immediate skin tests to yeast and showed improvement ranging from 65% to 80% on immunotherapy
  

In truth, allergic vaginitis is a well-defined clinically significant entity; there was a superb review article on this by Moraes, et. all in our own Annals of Allergy in October 2000. 

Now, I ask you, are there any follow-up articles, excited comments amongst allergists, letters to the editors, or frequent articles or talks at allergy meetings on this subject?  Nope.  None.  Zippo.  Dead end.  No curiosity.  No interest.  Void.  Null set.  All I hear is the sound of .....loud snoring...You see, we've got those blinders on, and we're too busy plodding down the 'ol respiratory tract road...Our heads are as empty as a 2 year old cannister of albuteral in the hands of a status asthmaticus patient...As Moraes and the other authors point out:

..."resulting symptomatic candidal vaginitis would be a secondary consequence to a primary allergic vaginitis"  (my emphasis)

And of course I don't have to tell you how big a problem recurrent yeast vaginitis is for women.  Like the fact that upwards of 70% of the general female population can have a yeast infection yearly.  But we don't care about that do we? 

In effect, allergic vaginitis is an "orphan illness" which nobody wants to "adopt".  Certainly not the gynecologist--and rightfully so, since they are not allergists and are not familiar with the allergic nuances of mucosal membranes, or with immunotherapy.  However, we as allergists have a bigger responsibility to deal with this illness, and I am confident if we work together with gynecologists we can much more effectively help our mutual patients with this difficult problem...

The vagina--an immunologically reactive mucosal surface.  Think about it...think about the potential to help others...pull the inhaler out of your mouth and get involved with treating this issue...Talk to your local gynecologist...Talk to your patients...Think about it...and be curious...after all, enquiring minds want to know.