Vulval candida (thrush)
What is thrush?
Thrush is an itchy, uncomfortable condition affecting the vulva and vagina. It is caused by a fungus (yeast) called Candida. Other terms that women use for this infection are “monilia” or “yeast infection”.
Thrush is very common indeed, but hardly ever occurs in girls prior to the onset of periods, or in women after the menopause (unless hormone replacement therapy is being used). This is because thrush needs enough female hormone (estrogen) in order to thrive in the vagina.
About 75% of women will experience an attack at some time in their lives. However for most women these attacks are not frequent and are easily treated with standard treatments from the chemist (antifungal pessaries, or a single oral tablet). This sort of thrush is called acute candidiasis. It is often the result of taking courses of antibiotics because antibiotics reduce the normal bacteria that live in the vagina, resulting in overgrowth of the fungus.
Some women who have very frequent attacks of thrush and others have symptoms all the time. These women have what is called chronic candidiasis.
What are the symptoms of acute candidiasis?
Itching, soreness, pain with intercourse and discharge are the typical symptoms of acute thrush. The onset is usually quite sudden. The vagina is inflamed and red. The symptoms recover within a few days of using standard antifungal treatments.
What are the symptoms of chronic candidiasis?
This condition is quite different from acute candidiasis. Although itching, soreness and pain with intercourse are present there is usually not a great deal of discharge. The symptoms may be constant, and often get worse in the week before menstruation, improving quickly on the first day of bleeding. The outside of the vulva and the vagina are red and there is often splitting of the skin at the opening to the vagina.
Courses of oral antibiotics often make the symptoms worse. Other things that also affect symptoms include overheating, sex, tight clothes and use of strong cortisone creams.
Many women with chronic candidiasis feel better when they use antifungal treatment, but usually find that the symptoms return quite quickly after the treatment is finished.
How is candidiasis diagnosed?
The best test is a low vaginal swab. This is a very easy test done by inserting a swab into the entrance to the vagina. The swab is sent to a lab for a test called a “culture” which takes about 2-3 days.
Unfortunately, this test is not always reliable. It will not show the fungus if you have recently used antifungal medications. In this situation, the test should be repeated at least two weeks after you have finished any thrush treatment. Sometimes your doctor may need to make the diagnosis of chronic thrush based on your symptoms and examination alone.
Can my partner catch this from me?
Some men whose partner has thrush will experience itching or a rash on their penis after intercourse. This responds quickly to antifungal cream. However you cannot cause a persistent infection in your partner, nor can your partner give thrush to you.
What causes candidiasis?
In the past it was believed that women with chronic candidiasis had a deficient immune system that made them prone to infection, however extensive research has not confirmed this. Although some women who have problems with their immune systems can be prone to fungal infections, women who have this are usually healthy in every other way. As a result there is no point in carrying out extensive testing or your immune system if you are otherwise healthy.
The latest research shows that chronic candidiasis may not be a true infection. We know that many women have positive vaginal swabs for candida without having any symptoms and that it is the minority with a positive swab who have so much trouble. It is thought that this group may be reacting to the presence of the fungus with a severe form of dermatitis. However it is not possible to get this dermatitis present without reducing the amount of thrush in the vagina.
How is chronic candidiasis treated?
At the moment the best treatment we have is prolonged treatment with an oral antifungal medicine, The two most often used are called fluconazole (Diflucan, Fluzole, Dizole, Ozole) and itraconazole (Sporanox). They are very safe, well tolerated medications and although many doctors warn about liver damage this is in fact a very rare complication.
The medication is usually taken continuously for 3 months or until symptoms go away. Many patients require maintenance treatment with a lower dose (once or twice a week) in order to stay symptom free.
The dermatitis that accompanies this condition is treated with a weak cortisone ointment called 1% hydrocortisone.
I would prefer natural treatment to pills. Isn’t there a diet that works?
We do know that the fungus thrives in a high sugar environment, which is why patients with uncontrolled diabetes are prone to thrush. As a result a very low sugar diet is often recommended. However this has never been adequately proved to work and it is very difficult to stick to.
Yoghurt and probiotics have not been shown to have any benefit.
Should I stop taking the oral contraceptive pill or hormone replacement therapy?
The pill usually does not promote chronic candidiasis, and therefore most women find that stopping the pill makes no difference to their infection. If you want to try stopping the pill, make sure you use adequate alternative contraception.
Post-menopausal hormone replacement therapy (HRT) on the other hand may cause chronic candidiasis. Women in this situation often need to stop HRT in order to get thrush under control.
What should I do if I think I might have chronic candidiasis?
See your doctor right away before you have used any antifungal medicine so that your swab test will be positive is candida is present.
Don’t be scared to take oral antifungal medication. It will make a very big difference to your symptoms.