Vaginal Yeast Infections: All You Need to Know

• What is vaginal candidiasis?
• Common Causes of Vaginal Yeast Infection
• Symptoms of Vaginal Yeast Infection
• Diagnosing Vaginal Yeast Infection
• Treatment for Vaginal Yeast Infections
• What is a Complicated Vaginal Yeast Infection?
• Recurrent Vaginal Yeast Infection
• Severe Symptoms of Vaginal Yeast Infection
• Vaginal Yeast Infection in Immunocompromised Persons
• Non-Candida Albicans Vaginal Yeast Infection
• Menopause
• Pregnancy
• Antibiotic Use
• Vaginal Probiotics
• Oral Contraceptive Pills (OCP) and Contraceptive Devices
• Prevention of Vaginal Yeast Infection

What is vaginal candidiasis?

Count yourself lucky if you are one of the twenty-five percent of women who have never had a vaginal yeast infection. The itching, burning, inflamed sensation accompanied by clumps of white discharge may seem to be a vaginal volcanic eruption. To say that this is one of the least pleasant experiences of womanhood is putting it mildly.

According to the Centers for Disease Control, vaginal yeast infections are the second most common cause of vaginitis, accounting for 20-25% of cases. An estimated 75% of women will have at least one episode, and 40%–45% will have two or more episodes. In 85-90% of cases, the cause of vaginal yeast infection is a fungus called Candida Albicans. Candida normally lives on the skin, inside the mouth, throat, gut, and vagina without causing any problems.

Candida vaginitis occurs when there is an imbalance in the vaginal flora. This imbalance allows the yeast to overgrow, thus causing an inflammatory response. The causes of vaginal microbial imbalance can range from stress to chronic illness to medication side effects.

Common Causes of Vaginal Yeast Infection:

• Antibiotics
• Pregnancy
• Obesity
• Diabetes
• Diets high in sugar and refined carbohydrates.
• High Alcohol Consumption
• Contraceptive Devices such as sponge and IUD
• Excess Stress
• Weakened Immune System
• Douching
• Intercourse

The US Office on Women’s Health confirms that a vaginal yeast infection is not a sexually transmitted infection. However, sexually active women are more likely to experience yeast vaginitis. There is evidence that vaginal yeast infections and oral-genital sex are linked. In addition, some men develop symptoms after having sexual contact with an infected partner.

Symptoms of Vaginal Yeast Infection:

• Vaginal itching or soreness.
• Pain during sexual intercourse.
• Pain or discomfort when urinating.
• Abnormal vaginal discharge, often white, thick, and curd-like.
• Redness, swelling, and cracks in the skin.

Diagnosing Vaginal Yeast Infection

Your doctor may choose to diagnose and treat your yeast infection over the phone. A telephone diagnosis and treatment are more likely to occur if you contact your doctor outside of routine business hours and your symptoms are severe.  Given the extreme discomfort of yeast infection symptoms, your doctor may advise over-the-counter treatment or a prescription if over-the-counter meds have failed. However, if the symptoms persist despite treatment, you will need to be seen to ensure the accuracy of your diagnosis.

In the office, your health care provider will take a thorough history and perform a pelvic exam. The pelvic exam involves placing a speculum into the vagina and taking a sample of the discharge using a small cotton swab. Your doc will test for yeast, trichomoniasis, and bacterial vaginosis. Depending on the testing type, results may be available within minutes or a few days. Suppose you are experiencing recurrent yeast infections, defined as four or more in a year. In that case, your doctor will test for the different types of yeast that may be present, not just the Candida Albicans. Depending on your symptoms, your doc may perform additional testing, searching for alternative diagnoses such as bladder infection and genital herpes.

Treatment for Vaginal Yeast Infections

There are varied treatments for yeast infection. There are over-the-counter creams. These are antifungal creams that are placed into the vagina nightly for 3-7 nights. It is best to place the intravaginal creams at night. Placing vaginal creams during the daytime, when you are most active, will cause most of the cream to leak out and make it less effective. The creams and suppositories used to treat the yeast infection are oil-based and might weaken latex condoms and diaphragms.

Prescription-strength creams are also placed intravaginally nightly for three nights. The prescription-strength cream is twice as strong as the over-the-counter cream.

You can also take antifungal tablets for the treatment of your vaginal yeast infection. The antifungal pills work as well as the cream and require only one tablet. Some prefer the use of the tablet due to the ease of use and convenience. In addition, the use of the pill avoids the burning and itching sensation that can occur with the initial use of the cream.

• Treatment results in a cure in 80-90% of cases.
• Recurrence of symptoms within two months of completing treatment requires a visit to your health provider for testing.

An estimated 75% of women will have at least one vaginal yeast infection in their lifetime.

What is a Complicated Vaginal Yeast Infection?

The American College of Obstetrics and Gynecology states that a complicated vaginal yeast infection meets one of four criteria:

1. Recurrent diagnosis, defined as four or more per year.
2. Severe symptoms.
3. Immunocompromised state (HIV, steroid use, cancer treatment, diabetes).
4. Non candida albicans infection. Infection with a yeast different from Candida Albicans.

Recurrent Vaginal Yeast Infection

Suppose you are diagnosed with a vaginal yeast infection four or more times yearly. In that case, this is considered recurrent and requires special treatment. First, your doctor will perform a vaginal culture. Vaginal cultures help to confirm that you genuinely have a vaginal yeast infection and not some other diagnosis that may present with similar symptoms.

Once the diagnosis is confirmed, your health care provider will treat you with either the vaginal cream or the oral antifungal tablet. Once you have completed your initial treatment, your doctor will recommend continued intermittent treatment to prevent the infection from coming back. Prolonged treatment with pills or creams for six months is necessary to clear up a recurrent yeast infection.

Treatment for Recurrent Vaginal Yeast Infection

• Fluconazole (Diflucan) tablet once weekly for six months.
• Vaginal cream once or twice weekly for six months.

Severe Symptoms of Vaginal Yeast Infection

Severe Symptoms of vaginal yeast infection include swelling, redness, and minor cuts along the area around the vagina. Severe symptoms require prolonged treatment, with either the intravaginal cream for 10-14 nights or multiple doses of the antifungal pill. Instead of taking one pill once, your doc may treat severe symptoms with one pill taken every three days for a total of 2-3 tablets. One study found that the cure rate increased from 67% to 80%, with just two doses.

Treatment Options for Severe Vaginal Yeast Infection

• Intravaginal Cream Nightly for 10-14 nights.
• One Antifungal Tablet every three days for a total of 2-3 tablets.

Vaginal Yeast Infection in Women with Weakened Immune System

Women with immunocompromised conditions may have difficulty clearing vaginal yeast infections. Persistent symptoms can be highly distressing and interfere with your quality of life.

Treatment is similar to that of severe infections. However, until you treat your underlying condition, vaginal yeast infections may continue to recur.

Non-Candida Albicans Vaginal Yeast Infection

Testing may show that your yeast infection is caused by some other culprit other than Candida Albicans. A non-Albicans candida causes 5-10% of yeast infections. The most common non-albican candida is called candida glabrata. Candida glabrata requires specialized testing to pinpoint its diagnosis. In addition, c. glabrata is more likely to be resistant to the commonly used therapies of creams and antifungal pills.

Your health care provider may treat your non-Albicans candida with boric acid vaginal capsules. Boric acid is a chemical used in the pest control industry. Boric acid is a poison and should never be ingested. Boric acid is a powerful antifungal that may treat certain types of resistant vaginal yeast infections. You may have to fill your boric acid prescription at a compounding pharmacy. There is no routine manufacture of boric acid vaginal suppositories. Compounding pharmacies put together medicines in dosages or combinations not made by the drug manufacturer. The typical dosing for this purpose is boric acid 600mg capsules, inserted nightly for a minimum of 14 nights. Boric acid must never be used in pregnancy. The use of boric acid for treating c. glabrata results in a cure rate of 64-71% in some studies.

Topical flucytosine cream is a recognized treatment for candida glabrata. Studies show that flucytosine cream is 90% effective in treating C. glabrata not cured by boric acid. Flucytosine cream, however, is exorbitantly expensive. The cost is a significant obstacle in its use for the treatment of vaginal candidiasis.

Infection nonresponsive to these regimens may require a referral to an infectious disease expert.

Menopause

Yeast infections thrive in moist estrogenized environments. For this reason, menopause can be protective from yeast infections. Bacterial Vaginosis rather than yeast vaginitis is more likely to occur in menopause. If vaginal candidiasis does occur, treatment is the same as in those women of reproductive age.

If you are diagnosed with a vaginal yeast infection four or more times yearly, this is considered recurrent and requires special treatment.

Pregnancy

Vaginal yeast infection is more common in pregnancy due to elevated estrogen levels. Thankfully, vaginal candidiasis does not harm your pregnancy or your baby. There is no evidence of miscarriages or preterm labor associated with vaginal yeast infections.

Treatment of vaginal yeast infection in pregnancy is usually limited to vaginal creams. You may use the cream in all trimesters of your pregnancy. Diflucan (Fluconazole) antifungal tablets are avoided in pregnancy, especially in the first trimester, to avoid fetal exposure.

Antibiotic Use

The use of antibiotics increases the likelihood of developing yeast vaginitis. Antibiotics alter the microbial environment in the vagina, causing the overgrowth of yeast. Yeast infections caused by antibiotic use are no different than those occurring in any other fashion and are treated the same.

Vaginal Probiotics

Vaginal probiotics are tablets containing live organisms marketed with the promise of restoring microbial balance within the vagina. These products have soared in popularity, but studies showing their effectiveness are lacking. Studies investigating the role of vaginal probiotics have been lacking in scientific standards. Their potential for benefit (or harm) is just not known.

Most women and their health care providers have turned to the use of vaginal probiotics out of frustration when nothing else seems to work. There is little evidence that the probiotics cause harm and so this is a reasonable approach. Vaginal probiotics with the most promise contain Lactobacillus rhamnosus GR-1 and Lactobacillus RC-14. Studies have shown that probiotics containing either of these two lactobacilli can restore the vaginal flora when used for 60 days in healthy women.

Keep in mind that probiotics are supplements. Supplements do not require FDA approval. They undergo very little scientific rigor before being presented to the public.

Oral Contraceptive Pills (OCP) and Contraceptive Devices

OCP and spermicides are not linked to an increased risk of vaginal yeast infections. Contraceptive devices such as intrauterine devices, diaphragms, and sponges are associated with an increased risk. Some yeast may attach to the IUD string or contraceptive device that allows a yeast infection to occur.

Prevention of Vaginal Yeast Infection

Fungus thrives in moisture. Keeping your underwear and vaginal area clean and dry is key in preventing vaginal yeast infections. Loose clothing that prevents the collection of sweat and moisture along the vagina is helpful. Going commando and ditching underwear at night helps to create ventilation around the vagina and maintain vaginal health.

Vaginal Yeast Infection Prevention Methods

• Always wipe from front to back after using the toilet.
• Wear loose clothing.
• Wear cotton underwear (allows air circulation and wicks away moisture).
• Do not wear underwear to bed at night.
• Avoid bubble baths, scented soaps, body washes, and douches.
• Use laundry detergent specially made for sensitive skin.

Relief of Symptoms

In addition to using the antifungal cream and pills, you may take measures to relieve the immediate symptoms while waiting for the medication to work.

• Sitz baths- a warm shallow bath used to irrigate the vaginal area.
• Use a cold compress to relieve swelling and discomfort.

Written by: Lisa Shephard, MD and Dayna Smith, MD | Editor: Dayna Smith MD | Reviewed September 10,2021 | Copyright myObMD. Media, LLC, 2021