Many women have an occasional bout of thrush, when treatment is usually easy and effective. There is a separate leaflet called 'Thrush - Vaginal' about a first or occasional bout of thrush. However, some women have recurring bouts of thrush, when treatment can be more difficult. This leaflet is for women who have recurring bouts of thrush.
What is thrush?
Thrush is an infection caused by a yeast fungus called Candida spp. Small numbers of Candida spp. commonly live on the skin and around the vaginal area. These are usually harmless. The immune system and the harmless bacteria that also normally live on the skin and in the vagina usually stop Candida spp. from thriving. However, when conditions are good for Candida spp., numbers multiply and may invade the vagina and cause symptoms.
The conditions most liked by Candida spp. are warm, moist, airless parts of the body. This is why the vagina is the most common site for candidal infection. Other areas of the body that are prone to candidal infection include the groin, the mouth, and the nappy area in babies.
Most cases of thrush are caused by Candida albicans but sometimes other types of Candida spp., such as Candida glabrata or Candida tropicalis, are the cause.
What are the symptoms of vaginal thrush?
Thrush is the second most common cause of a vaginal discharge. (The most common cause of vaginal discharge is bacterial vaginosis. A separate leaflet called 'Bacterial Vaginosis' gives more details.)
The discharge from thrush is usually creamy white and quite thick, but is sometimes watery. It can cause itch, redness, discomfort, or pain around the outside of the vagina (the vulva). The discharge from thrush does not usually smell. Some women can have some pain or discomfort whilst having sex or whilst passing urine if they have thrush.
Sometimes symptoms are minor and clear up on their own. Often symptoms can be quite irritating and will not go without treatment.
Thrush does not damage the vagina, and it does not spread to damage the uterus (womb). If you are pregnant, thrush will not harm your baby.
Who gets vaginal thrush?
Many women have an occasional bout of thrush. In most cases it develops for no apparent reason. However, some women develop recurring thrush. This is defined as a bout of thrush four or more times a year. In most cases, the reason this occurs is not known. Some women just seem more prone to develop thrush than usual.
However, certain factors can make thrush more likely to develop. The vagina contains mucus and some harmless bacteria which help to defend the vagina from Candida spp. (and other germs). These natural defences may be altered or upset by certain situations - for example, when you are pregnant, if you have diabetes, or if you take antibiotics. So, in these situations, you may be more likely to develop thrush. People with a poor immune system are also more likely to get thrush - for example, people on chemotherapy for certain cancers, people taking high-dose steroids, etc.
Of women who get a first bout of vaginal thrush, about 5 in 100 of them will get problems with recurring vaginal thrush.
Do I need any tests?
You do not always need a test to diagnose thrush. If you have had thrush in the past and the same symptoms recur, then it is common practice to treat it without an examination or tests. Thrush is common and many women recognise when they have thrush.
However, there are other causes of vaginal discharge. If symptoms are not typical or the same as you usually get, or if you are having recurring symptoms, then your doctor or nurse may examine you and take small samples of the discharge with swabs. These are sent to the laboratory to confirm the cause of the discharge. Also, the doctor or nurse may also check a urine sample if you have recurring thrush, to rule out diabetes.
What are the treatment options for vaginal thrush?
These are pessaries and creams which you insert into the vagina with an applicator. They contain anti-yeast medicines such as clotrimazole, econazole or miconazole. Commonly, a single large dose inserted into the vagina is sufficient to clear a bout of thrush. However, you may also want to rub some anti-thrush cream on to the skin around the vagina (the vulva) for a few days, especially if it is itchy. You can get topical treatments on prescription, or you can buy them at pharmacies without a prescription. Side-effects are uncommon, but read the information leaflet that comes with the treatment for full information.
In general, you can use these topical treatments if you are pregnant but you should check with your doctor or pharmacist. Treatment may be needed for longer during pregnancy.
Note: some pessaries and creams may damage latex condoms and diaphragms and affect their use as a contraceptive.
Two options are available. Fluconazole, which is taken as a single dose, or itraconazole which is taken as two doses over the course of one day. You can get these treatments on prescription, and you can also buy fluconazole without a prescription from pharmacies. Side-effects are uncommon, but always read the information leaflet that comes with the treatment for full information. Do not take these treatments if you are pregnant or breast-feeding. You may also want to rub some anti-yeast cream on to the skin around the vagina for a few days, especially if it is itchy.
Note: tablets and topical treatments are thought to be equally effective. Tablets are more convenient, but are more expensive than most topical treatments.
What if the treatment does not work?
If you still have symptoms a week after starting treatment, then see your doctor or nurse. Treatment does not clear symptoms in up to 1 in 5 cases. Reasons why treatment may fail include:
- The symptoms may not be due to thrush. There are other causes of a vaginal discharge. Also, thrush can occur at the same time as another infection. You may need tests such as vaginal swabs to clarify the cause of your symptoms.
- Most bouts of thrush are caused by Candida albicans. However, about 1 in 10 bouts of thrush is caused by other strains of Candida spp. such as Candida glabrata. These may not be so easily treated with the usual anti-thrush medicines.
- You may not have used the treatment correctly.
- You may have had a quick recurrence of a new thrush infection. (This is more likely if you are taking antibiotics, or if you have undiagnosed or poorly controlled diabetes.)
What can I do to prevent vaginal thrush recurring?
The following tips may help. However, they have not been proven to work by research, and their use is based on common practice rather than research studies:
- Hygiene. Thrush is not due to poor hygiene. However, the normal conditions of the vagina may be altered by excess washing and douching of the vagina, bubble baths, scented soaps, spermicides, etc. The normal mucus and bacteria in the vagina may be upset by these things and allow Candida spp. to infect. Therefore, it may be best to wash just with water and unscented soap, and not to douche the vagina.
- Clothes. Don't wear nylon underwear or tight-fitting jeans too often. Loose cotton pants are best. Stockings rather than tights are preferable. The aim is to prevent the vaginal area from being constantly warm, moist, and airless.
- Antibiotics. Be aware that thrush is more likely if you take antibiotics for other conditions. Antibiotics may kill the normal harmless bacteria in the vagina which help to defend against Candida spp. As Candida spp. is a yeast and not bacteria, this will not be killed by antibiotics. This is not to say that every course of antibiotics will lead to thrush. But, if you are prone to this problem and you are prescribed antibiotics, then have some anti-thrush cream ready to use at the first sign of thrush.
- Sex. Thrush is not a sexually transmitted disease. However, friction when you have sex may cause minor damage to the vagina which may make Candida spp. more likely to thrive. So, make sure your vagina is well lubricated when having sex. If natural secretions are not sufficient then use a lubricant when you have sex.
There is no consistent evidence that the contraceptive pill, tampons, or sanitary towels increase the risk of getting thrush as some people may suggest.
What is the treatment for recurrent vaginal thrush?
If you have recurrent bouts of thrush then one option is simply to treat each bout as and when it occurs. Another option that your doctor may suggest is as follows:
- Use one of the treatments described above (topical treatments or tablets) - but for longer than usual. Your doctor will advise exactly how long to use the treatment for. For example, this may be for 7-14 days for topical treatments.
- Then use a topical treatment or take a fluconazole tablet once per week. (Sometimes other tablets may be prescribed, follow the instructions given by your doctor.) This is called maintenance treatment, which often prevents thrush from recurring.
- Continue maintenance treatment for six months and then stop.
Most women remain clear of thrush during maintenance treatment. After treatment is stopped, many of those treated remain free of thrush, or only get the occasional bout again. However, some women return to getting recurrent thrush. In such cases, if necessary, the treatment plan can be repeated, and maintenance treatment continued for longer.
See your doctor if you develop thrush whilst on maintenance treatment. This may indicate that you have a resistant strain of Candida spp. which may require an alternative treatment.
Do I need to see a doctor if I get vaginal thrush?
If you have had thrush in the past and the same symptoms recur, then it is common practice to treat it without an examination or tests. Many women know when they have thrush and treat it themselves. You can buy effective treatments (discussed above) without a prescription from pharmacies.
However, remember, a vaginal discharge or vulval itch can be due to a number of causes. So, do not assume all discharges or itch are thrush. The following gives a guide as to when it may be best to see a doctor or nurse if you think that you might have thrush. If you:
- Are under 16 or over 60 years of age.
- Are pregnant.
- Have abnormal vaginal bleeding or lower abdominal pain.
- Are unwell in yourself in addition to the vaginal and vulval symptoms.
- Have symptoms that are not entirely the same as a previous bout of thrush. For example, if the discharge has a bad smell, or it you develop ulcers or blisters next to your vagina.
- Have had two episodes of thrush in six months, and have not consulted a doctor or nurse about this for more than a year.
- Have had a previous sexually transmitted infection (or your partner has).
- Have had a previous bad reaction to anti-thrush medication or treatments.
- Have a weakened immune system - for example if you are on chemotherapy treatment for cancer or are taking long-term steroid medication for whatever reason.
And, if you do treat yourself, see a doctor or nurse if the symptoms do not clear with treatment.
Some other points about vaginal thrush
- 'Natural' remedies for thrush include: live yoghurt inserted into the vagina; adding vinegar or bicarbonate of soda to a bath to alter the acidity of the vagina; tampons impregnated with tea tree oil. However, at present, there is little scientific evidence to show that these remedies work but some women may find that they help soothe their symptoms.
- Thrush is not a sexually transmitted infection. Candida spp. is a yeast germ which commonly occurs on the skin and vagina. For reasons not quite clear, it sometimes multiplies to cause symptoms.
- Male sexual partners do not need treatment unless they have symptoms of thrush on their penis. Symptoms in men include redness, itch, and soreness of the foreskin and the head (glans) of the penis. Women do not catch thrush from men who have no symptoms.
Further reading & references
- Management of vulvovaginal candidiasis, British Association for Sexual Health and HIV (2007)
- Abad CL, Safdar N; The role of lactobacillus probiotics in the treatment or prevention of urogenital J Chemother. 2009 Jun;21(3):243-52.
- Nurbhai M, Grimshaw J, Watson M, et al; Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of Cochrane Database Syst Rev. 2007 Oct 17;(4):CD002845.
- Spence D, Melville C; Vaginal discharge. BMJ. 2007 Dec 1;335(7630):1147-51.
- Sobel JD; Vulvovaginal candidosis. Lancet. 2007 Jun 9;369(9577):1961-71.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Tim Kenny
Dr Michelle Wright