Recurring Vaginal Thrush

What is thrush?

Thrush is an infection caused by a yeast called Candida. Small numbers of Candida commonly live on the skin and around the vaginal area. These are usually harmless. The immune system and the harmless bacteria that normally also live on the skin and in the vagina usually stop Candida from thriving. However, when conditions are good for Candida, it multiplies and may invade the vagina and cause symptoms.

The conditions Candida likes best are warm, moist, airless parts of the body. This is why the vagina is the most common site for Candida infection. Other areas of the body that are prone to Candida infection include the groin, the mouth, and the nappy area in babies.

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.) The discharge from thrush is usually creamy white, but is sometimes watery. It can cause itch, redness, discomfort, or pain around the outside of the vagina. 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 it will not harm your baby.

Who gets vaginal thrush?

Many women have an occasional bout of thrush. In most cases it develops 'out of the blue' 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 (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.

People with a poor immune system are also more likely to get thrush. For example, people on chemotherapy, people taking high dose steroids, etc.

Do I need any tests?

Usually not. 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 recognize when they have thrush. However, there are other causes of vaginal discharge. If symptoms are not typical or the same as you usually get then a doctor or nurse may examine you and take small samples of the discharge with swabs. These are sent to the lab to confirm the cause of the discharge. 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?

Topical treatments

These are pessaries and creams which you insert into the vagina with an applicator. They contain anti-yeast medicines such as clotrimazole, econazole, fenticonazole, 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-yeast cream onto 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 product label for full information.

Tablets

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 from pharmacies without a prescription. Side-effects are uncommon, but always read the product label for full information. Do not take these if you are pregnant or breastfeeding. You may also want to rub some anti-yeast cream onto the skin around the vagina for a few days, especially if it is itchy.

Tablets and topical treatments are 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 after a week from starting treatment, 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 vaginal swabs taken to clarify the cause of the discharge or other symptoms.
• Most bouts of thrush are caused by Candida albicans. However, about 1 in 10 bouts of thrush are caused by other strains of Candida such as Candida glabrata. These may not be so easily treated with the usual anti-yeast 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 are 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 to infect. Therefore, it may be best to wash just with water and unscented soap, and do not 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. As Candida is a yeast and not a 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 'nip it in the bud' 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 more likely to thrive. So, make sure the vagina is well lubricated when having sex. If natural secretions are not sufficient then use a lubricant when you have sex.

There is no 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 or tablets) - but for longer than usual. That is, for 7-14 days.
• Then use a topical treatment or take a fluconazole tablet once per week. Or, take a dose of itraconazole tablets once a month. 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, about half of those treated remain free of thrush, or only get the occasional bout again. The other half return to getting recurrent thrush. However, 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 which may require an alternative 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, there is little scientific evidence to show that these remedies work.
• Thrush is not a sexually transmitted infection. The thrush yeast (candida) is a germ which commonly occurs on the skin and vagina. For reasons not quite clear, it sometimes multiplies, thrives and causes 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 of the penis. Women do not catch thrush from men who have no symptoms.