Acute, Chronic and Recurrent Candida

What is Acute, Chronic and Recurrent Candida?

Vaginal thrush is a common infection caused by a yeast. From these, 90% are Candida Albicans and 10% of infection belongs to other types of Candida which may not cause symptoms. Another name for vaginal thrush is candidiasis or yeast infection. Over one half of women will have vaginal thrush at least once in their lifetime and about 5% of women have frequent episodes.

What are the symptoms?

• genital itch – this is the most common symptom of thrush. Itching may be especially worse before your period begins
• soreness or burning in the vagina during or after intercourse
• abnormal discharge – can be thick and white
• a change in the smell of your vaginal secretions
• redness and inflammation of the outside genital skin (vulva)
• soreness or discomfort on urination
• pain – particularly if the infection occurs a number of times and has not had the correct treatment
• small white spots on the vaginal wall or curds in the discharge

How is this condition diagnosed?

Diagnosis of vaginal thrush is often made based on a number of different points including your symptoms, physical examination, examination of vaginal secretions under the microscope and a vaginal culture. There are many other conditions of the vagina and vulva that have symptoms in common and even associated with thrush, so if there is doubt about the diagnosis, it is essential that a vaginal swab is taken for laboratory testing before treatment is commenced.

What can you do to help yourself?

Treatment with a cream or ovules (pessaries) in the vagina or the use of an oral anti-fungal tablet/capsule are two effective means of treating thrush. There are many different names for these creams and ovules/pessaries and they usually come with an applicator that helps to insert them deep in the vagina. Even if your period starts, you can still use these medications. The medication is available over the counter from your local pharmacy and can be used to treat an isolated episode of thrush (one that occurs more than a year since the previous episode).

Vaginal thrush may also be treated with anti-fungal tablets or capsules that you take by mouth and these medications are best administered under the supervision of your medical practitioner. Fluclonazole is not safe for pregnant women to take however oral nystatin tablets are safe to use in pregnancy.

When should you seek medical advice?

• This is the first time you have experienced symptoms of thrush
• You are not sure if the problem you have is thrush
• This is the second thrush infection you have had in less than a year
• You are pregnant or breastfeeding
• You have not responded to treatment and there is no improvement

If symptoms come back in less than a year, or your response to treatment is unsatisfactory, do not self-treat or you risk producing a chronic (ongoing) condition.

When you see your doctor, make sure that the diagnosis is confirmed with a swab sent for laboratory testing. Please note that swabs may not produce useful or accurate results if any treatment has been used in the week or so before the swab is taken.

How do you get vaginal thrush?

The yeast that causes vaginal thrush, can live in the mouth and bowel without causing any problems. It can travel to the vagina from the anus via the perineum – the area between the anus and vagina. Other species of yeast can live in the vagina but can cause no harm.

Candida albicans causes the most severe symptoms of vaginal thrush.

Women are more likely to get vaginal thrush between puberty and the menopause as under the influence of the hormone oestrogen, the cells lining the vagina produce a sugar. Yeasts feed on these sugars. Therefore, thrush is rare before puberty, in breast feeding women (who have a low circulating oestrogen) and after the menopause, unless a woman is taking menopausal hormone therapy (MHT) or has diabetes.

How can you avoid getting thrush?

Although numerous lifestyle changes have been suggested in the past to prevent thrush. These include avoiding sugars, tight clothing and alteration of sexual practices. None of these have been proven to be effective. Candida albicans is not sexually transmitted.

Antibiotics promote the growth of yeasts by destroying the bacteria that can protect against them, so are best avoided unless necessary. If you are a diabetic then good control of blood sugar levels is helpful. Contrary to popular belief, the oral contraceptive pill makes no significant difference to a woman’s chance of getting thrush. The long- acting progesterone contraceptives, medroxyprogesterone acetate  (injections) and estonogestrel rod (implant), however, do lower the incidence of thrush as they suppress ovarian production of oestrogen and contain no oestrogen themselves. If an oral contraceptive is needed, it is best to have one that contains a low oestrogen level. Breast feeding has the same effect, which is why vaginal thrush is seldom a problem in breast feeding women.

What to do if thrush keeps coming back? (Chronic and recurrent thrush)

A small number of women will experience thrush more than once a year. This is called recurrent candidiasis and is best managed by a gynaecologist with a special interest in this area.
If you have recurrent thrush, you should never treat yourself. Your doctor should take a vaginal swab with each episode of thrush to monitor your condition. Occasionally tests need to be taken to see whether the candida is resistant to the treatment that is being used. Chronic fungal infections of the vulval skin can occur even with negative swabs.

Treatment choices for recurrent thrush include:

• combined oral and vaginal azole therapy – this means taking tablets as well as using anti-candida creams inserted in the vagina – medium term (three weeks of vaginal cream +/- one or two doses of oral antifungal treatment)
• long term (at least six months) treatment with an oral azole
• a change of contraception to medroxyprogesterone acetate (injection) or etonogestrel (implantable rod)
• a change to a lower oestrogen dose for women taking MHT
• boric acid made into vaginal pessaries by a compounding chemist – especially if the fungus is one of the 10% of cases that are not related to candida albicans

Dr Kliman will visualize your vulval skin with a microscope to identify the typical changes of chronic vulval fungal infection.

Thrush is not a sexually transmitted disease. Generally, no benefit is shown by treating the male sexual partner of women with recurrent vaginal thrush. Treatment is recommended for men only when they have symptoms themselves, preferably after swabs have been taken and candida albicans has been confirmed.