Introduction

Vaginal candidiasis also known as vaginal thrush is an infection of the vagina involving an overgrowth of a type of yeast commonly known as Candida albicans. It is a common problem and usually affects women of child bearing age and is uncommon before menarche or after menopause. This type of yeast is normally present in the mouth, gut and vagina and unless there is an overgrowth, it is not a problem. Up to 15% of healthy women may be colonised by it but they remain asymptomatic (1). Women who have no symptoms do not need to be treated. However in patients with HIV (2) and among pregnant women the incidence of vaginal ‘yeast infection’ may be higher (1). Up to 15% of patients who are immunocompromised or those with low immunity may develop a more serious form of systemic Candida infection.

What are the risk factors for vaginal candidiasis?

Some of the risk factors that increase the susceptibility for a woman to develop vaginal Candida infection include:

• Antibiotic therapy
• Pregnancy
• Uncontrolled Diabetes Mellitus
• Obesity
• Suffering from HIV (2)
• On high dose steroids
• Stress
• Those on cancer treatment (chemotherapy)
• Nutrient deficiency

Antibiotic therapy can alter the protective bacteria (lactobacilli) in the vagina and promote Candida overgrowth (3,4). High reproductive hormones (estrogen and progesterone) during pregnancy causes decrease in immune response and may lead to increased susceptibility of a woman to get vaginal Candida infection (5). In the pre-pubertal and post menopausal period, the level of these hormones are low and thus vaginal candidiasis is not common in this age group.

Is vaginal candidiasis a sexually transmitted disease?

Vaginal candidiasis is not a sexually transmitted disease. However, a small number of male sexual partners may develop symptoms such as itching and a rash on the penis after having sexual contact with an infected partner. The partner does not need to be treated unless he has symptoms (6).

What are the symptoms and signs of vaginal candidiasis?

Symptoms of vaginal candidiasis are itching, burning sensation, pain during intercourse, soreness, painful urination and irritations. On vaginal examination,a doctor may find swelling and redness of the vulva and the presence of thick whitish to yellowish vaginal discharge (curd-like appearance) in the vagina. The appearance of the discharge is quite typical to an experienced doctor but other vaginal infections such as bacterial vaginosis or gonorrhoea may have somewhat similar symptoms and signs as the ‘yeast infection’.

Your doctor may need to send a vaginal swab specimen for miscroscopic examination for Candida or gonotthoea. Alternatively a high vaginal swab for culture and sensitivity to ascertain the presence and type of infection may also be needed.

What are the available treatments?

Commonly available treatments are vaginal pessaries such as (1);

1. Clotrimazole vaginal pessary 500mg single dose or 200mg daily for 3 days
2. Econazole vaginal pessary 150mg single dose at bedtime or 150mg for 3 nights
3. Fenticonazole vaginal pessary 600mg single dose or 200mg for 3 days
4. Miconazole vaginal pessary 1.2g single dose or 200mg for 3 days
5. Teconazole vaginal pessary 80 mg daily for 3 days
6. Nystatin vaginal pessary 100,000 units for 14 nights

Oral medications such as fluconazole are also available and provide an alternative route for women who dislike ‘messy’ vaginal pessaries. It is very effective and would be the preferred choice in systemic candida infection and those with low immunity such as in HIV patient, cancer patient on chemotherapy and those with recurrent infection.

Oral anti-fungal should not be taken during pregnancy and breast feeding as safety have not been established. Local treatment like vaginal pessaries, vaginal tablet or creams have been shown to have fewer side effects than oral treatment, thus safer to use in pregnancy or during breast feeding.

How to prevent from getting the vaginal candidiasis infection?

• Avoid tight-fitting synthetic undergarment
• Avoid local irritants (perfume products)
• Replace soap with vulval water based moisturizers
• Keep the perineum dry and clean
• If you are suffering from Diabetes Mellitus you should keep your glucose under control
• If you are suffering from HIV, having a high CD4 (CD4> 350) and low viral load helps (2). If your CD4 count is low or viral load high, anti-retroviral treatment will improve the CD4 count and reduce viral load which in turn will reduce the risk of getting vaginal candidiasis.

What should I do if I suffer from recurrent vaginal yeast infection?

Recurrent Vaginal Candida infection occurs when a woman has four or more infections in a year (4). It occur in 5-8% of women in the reproductive age group. There are several predisposing factors for recurrent vaginal candidiasis (1);

• Women who are Immuno-suppressed like those with AIDS (5)
• Women with uncontrolled Diabetes Mellitus
• Women on long term steroid
• Women on chemotherapy
• Virulent yeast strains
• Yeast strains that are resistant to anti-fungal

If you suffer from recurrent vaginal thrush, your doctor may prescribe different types of medications based on the culture and sensitivity result of vaginal swabs. Treatment may include longer duration of oral anti-fungal or vaginal pessary or even cyclical therapy.

Various types of prophylaxis of anti-fungal therapy regime such as tablet Fluconazole 150 mg weekly for 6 months (1) may be ordered by the doctor. Prophylactic treatment of the asymptomatic sexual partner generally does not help in reducing the incidence of recurrent vaginal candidiasis (6).

What should I do if I have vaginal candidiasis infection?

You can go to your family doctor, private practitioner or a health care provider at the nearest government health clinic for assessment and appropriate treatment.

References

1. Sobel, J. (1998). “Recurrent vulvovaginal candidiasis.” MMWR Morb Mortal Wkly Rep 47: 75-79.
2. Ann Duerr et al.( 2003). “Incident and Persistent Vulvovaginal Candidiasis Among Human Immunodeficiency Virus–Infected Women: Risk Factors and Severity”. The American College of Obstetricians and Gynecologists. VOL. 101, NO. 3.
3. MacDonald, T. M., P. H. G. Beardon, et al. (1993). “The risks of symptomatic vaginal candidiasis after oral antibiotic therapy.” QJM 86(7): 419.
4. Lynda V.W et al ( 2003). “Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women”. Drug safety ; 26 (8): 589-597
5. Fidel Jr, P. L., J. Cutright, et al. (2000). “Effects of reproductive hormones on experimental vaginal candidiasis.” Infection and immunity 68(2): 651.
6. Fong, I. W. (1992). “The value of treating the sexual partners of women with recurrent vaginal candidiasis with ketoconazole.” Genitourinary medicine 68(3): 174.