Such tubes are made of soft metal-like zinc but with an internal layer of polymer plastic coating the interior surface to prevent metal contamination or any reactive ingredients from chemically reacting with the metal walls. The defect comes when the user squeezes and deforms the tube walls to such an extent that the internal plastic layer fractures into small chips and delaminates from its attachment to the wall. What results are a myriad of small and almost microscopic flakes of the lining plastic, with sharp points and razor-sharp edges like broken glass mixing into the cream product as it is delivered. Such a production of tissue-cutting particles will cause visible to microscopic lacerations in the delicate barrier tissues it comes into contact with and thus allow infections to occur or reoccur.

This should be the first thing a woman needing such a product should look at and demand an alternative to. Plastic-walled cream-delivery tubes or pre-filled syringe packaging would eliminate this kind of injury. Inform and warn your readers, please. Perhaps others have experienced the same, and an informed buying public has a great deal of economic clout when it comes to forcing improvements in product designs.

As an aside, the case was ultimately settled quietly after I demonstrated to both sides that this was the defect in the product leading to her injuries. I am not sure whether the makers of such products have changed from that design of packaging and delivery or not. But in my considerable experience with product-defect cases, including medical device-based cases, it is a rarity that the manufacturer has voluntarily eliminated such a defect. It’s usually an economic decision for them, and the cost of a few legal cases a year is just cranked into a slightly higher product price in the following years. The actual costs of their errors is in reality much greater when you factor in those who have sustained injury or worse but have not filed for or prevailed in legal actions.

DEAR READER: I have chosen to print your letter almost in its entirety because it is a well-written, informative piece. I thank you for bringing an alternate cause to the table, one I had never even thought to consider.

I, like you, am unaware of what type of packaging Premarin and similar estrogen creams come in; therefore, I am hoping that this letter is either late (in the case of newer, safer packaging) or will bring greater attention to this issue.

If packaging has not been improved, there may be many women suffering the effects who either don’t know the cause or are too embarrassed to bring up the issue with their general physicians or gynecologists.

Vaginal infections are often minor and disappear with treatment, but if left untreated can result in considerable symptoms and problems. I urge any woman who has symptoms of a vaginal infection to speak with her gynecologist so that she may receive appropriate treatment early before the infection can take hold and cause even greater discomfort, embarrassment and, perhaps, even damage.

As I have said many times in the past, there is no reason to be embarrassed by symptoms for any condition. Doctors have been there and done that. Any physician worth his salt will do his best to get to the bottom of the problem and offer help, support and treatment.

Readers who would like related information can order my Health Report “Vaginal Infections and Disorders” by sending a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print an order form off my website at www.AskDrGottMD.com.

After my last infection, a biopsy was done. The report said: “Vulvar Biopsy: Ulceration with very severe active chronic inflammation and numerous plasma cells. A serology for spirochetes was negative.” The microscopic description said: “The skin surface is covered by squamous epithelium which is moderately to extensively eroded. There are superficially dilated capillaries and there is a dense infiltration of lymphocytes and plasma cells in the upper dermis. Warthin-Starry stain is negative with appropriately reacting controls. Immunostain for AE1/AE3 is negative for epithelial component. Positive and negative controls worked as expected.”

My concern is that the Premarin cream is now making my ankles swell, and my blood pressure has gone up. (It is usually normal.) Also, when I call my OB/Gyn, I am no longer asked to come; they simply call in a prescription. I am never told to return for a follow-up and feel that this is because I am on Medicare. So far, this has happened with three separate gynecologists.

Do you have any advice or help to offer me?

DEAR READER: Let’s start with the biopsy report. First, ulceration is easy to understand. This simply means that you have a sore. Whether it was caused by scratching or something else is unclear. Inflammation means swelling. Again, this could be caused by scratching or the infection itself.

The identification of numerous plasma cells is more telling. These cells are a type of short-lived antibody-producing leukocyte (a type of white blood cell) that binds with a foreign substance (or what the body perceives to be a foreign substance) and then begins to neutralize or destroy it. Lymphocytes are another type of leukocyte and determine the specificity of the immune reaction to foreign substances and infectious agents.

All of this indicates that your body is fighting off an infection of some sort, is incorrectly attacking normal cells, or is overreacting to a substance you have come into contact with, such as perfumed feminine-hygiene products.

Now, on to what is causing your so-called yeast infection. First, you do not say what symptoms you are experiencing, so I will first review them. These can range from mild to severe and include redness and swelling of the vulva; itching, irritation, pain and/or soreness of the vulva and vagina; a thick, white, odor-free vaginal discharge similar in appearance to cottage cheese; and a burning sensation.

Yeasts are typically present within a normal vagina and in most instances do not present problems. For several reasons, yeasts can multiply and cause symptoms of an infection. In most cases, Candida albicans is the culprit. Thankfully, this type of yeast can be treated easily.

People who have never had a yeast infection before, have more than four a year, or fail to improve with treatment may require extensive testing, including cultures of any discharge or vaginal secretions. Long-term or multidose oral medications and maintenance regimens may be appropriate.

If you truly have a yeast infection, it is either not being treated properly and eradicated completely or it is the result of an underlying condition, such as long-term antibiotic use, uncontrolled diabetes or something else. Return to your gynecologist and demand answers or get a fourth opinion.