In this article:
- Thrush refers to the overgrowth of a yeast species known as Candida albicans and can affect both men and women.
- Vaginal thrush can be easily treated with prescribed or OTC antifungal medicines.
- In some complicated cases, vaginal thrush may be difficult to treat and may even recur frequently.
Thrush, medically known as vaginal candidiasis, is a common yeast infection of the vagina due to an overgrowth of Candida species. Candida albicans is responsible for 80%-92% of episodes of vaginal candidiasis in the United States and Candida glabrata accounts for almost all of the remainder of infections. (1)
Vaginal thrush is also called moniliasis or candidal vulvovaginitis. Candida species is identified in 10%-20% of healthy women in the reproductive age group, 6%-7% of menopausal women, and 3%-6% of prepubertal girls. (2)
Although this yeast, along with certain species of bacteria, is part of the normal, healthy microflora of the intestines and vagina, an increase in its numbers can lead to problems.
The symptoms of vaginal thrush may cause vulvar and vaginal pruritus/irritation and discomfort. However, self-diagnosis of vulvovaginal candidiasis is frequently inaccurate and should be discouraged.
In one study, questionnaires were distributed to 600 women to assess their knowledge of the symptoms and signs of vulvovaginal candidiasis. Results showed that only 11% of the women without a previous history of candidiasis correctly diagnosed this infection. (3)
It was also found that the women with a prior episode were more often correct (35%) but were likely to use over-the-counter drugs inappropriately and inadequately to treat other potentially more serious gynecologic problems. (3)
In some women, the infection may be challenging to treat with multiple recurrences, known as recurrent vaginal thrush.
Causes of Vaginal Thrush
The chief cause of vaginal thrush is the overgrowth of Candida species that penetrates the superficial cells of the vagina.
Generally, a healthy vagina maintains slightly acidic conditions through self-regulation, along with the help of good bacteria such as lactobacilli. The acidity keeps the yeast growth in check. An imbalance in the good bacteria can result in a yeast infection or thrush.
Various risk factors include:
- Antibiotics: Taking antibiotics may kill some good bacteria that keep the growth of Candida in check.
- Hormones: The hormonal changes associated with the onset of puberty can lead to yeast infections. Additionally, women are vulnerable to thrush outbreaks during ovulation or menstruation. Pregnancy and postmenopausal estrogen therapy are also risk factors for vulvovaginal candidiasis due to the increased estrogen levels.
- Contraceptive devices: Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with vulvovaginal candidiasis, but not consistently.
- Sexual behavior: An increased frequency of vulvovaginal candidiasis has been reported at the time most women begin regular sexual activity.
- Immune response: A weak immune system, due to any illness or medications, is unable to fight an infection caused by Candida overgrowth.
- Underlying conditions: Diabetes causes a rise in blood sugar levels, therefore increasing the risk of yeast infections. Iron deficiency can also contribute to thrush.
Symptoms of Vaginal Thrush
The symptoms associated with vaginal thrush vary widely. Some women do not experience any symptoms, whereas others may manifest the following:
- Thick yellow/white discharge with a cottage cheese appearance
- Itchiness or irritation around the vaginal and vulvar area
- Inflammation in the vagina or vulva
- Stinging sensation while urinating
- Redness on the external skin of the vagina with a whitish coating
- Pain and discomfort during sexual intercourse
- Sores or cracks on vaginal skin
Recurrent Vaginal Thrush
Vaginal thrush is considered to be recurrent when at least four discrete episodes occur in one year or at least three episodes occur in one year and are not related to antibiotic therapy. There has to be a symptom-free interval in between the episodes to distinguish it from persistent candidiasis.
It is vital to get recurrent vulvovaginal candidiasis clinically evaluated to identify the underlying cause or concurrent infection, which cannot be determined through self-diagnosis.
Recurrent candidiasis does not always manifest as vaginal discharge. Instead, it causes a burning sensation, inflammation, redness, irritation, and soreness in the vulvovaginal area. It may also cause vulval fissures (skin splitting) and extreme discomfort and pain during sex.
Diagnosing Vaginal Thrush
Thrush can be mistaken for a variety of other conditions that cause itching and redness, either with or without discharge. It is suggested to visit a medical professional if you notice any vaginal or vulvar irritation or abnormal discharge.
To diagnose the condition, the doctor will:
- Evaluate your symptoms
- Examine your genitals
- Take a vaginal swab for culture and microscopic examination
If your infection is recurrent, the doctor may also perform tests to rule out medical conditions such as HIV and diabetes. It is suggested to get thrush checked and treated by a medical professional. Self-diagnosis and treatment are discouraged.
Just as “all that glitters is not gold,” all that itches is not yeast. Patients often come with a self-diagnosis of “chronic yeast infections” based only on subjective symptoms of itching, but hardly any of these cases are later diagnosed as vaginal thrush on closer medical examination.
In some cases, the initial test can even give a false result only to be disproved by subsequent evaluation. For this reason, all infections should be thoroughly evaluated at least three times before establishing a diagnosis of chronic or recurrent vaginal thrush.
Women with previous episodes may try to treat with over-the-counter medications. However, doing so might be inadequate or inappropriate treatment and may cause delayed diagnosis of other gynecological disorders.
Medical Treatment for Vaginal Thrush
The standard treatment for mild cases of vaginal thrush involves the use of antifungal medications, which help subside the symptoms in 1-2 weeks.
These medications are available in different forms, including:
- Intravaginal capsules: Pessaries are pills that you can insert into your vagina using a special applicator. It is important to use the applicator carefully, especially if you are pregnant, to avoid injuring the cervix. Often, pregnant women prefer inserting pessaries by hand.
- Intravaginal creams: These creams are applied in and around the vagina. The most common OTC creams include clotrimazole and miconazole nitrate and are considered safe and effective for use in the treatment of mild to moderate vaginal candidiasis.
These creams are applied using an applicator. When applied to the skin surrounding the vagina, these creams help subside soreness and itchiness. However, a moisturizer can also be used for this purpose. Intravaginal creams can cause redness and inflammation in some cases.
- Oral pills: The common antifungal capsules taken orally are:
- Fluconazole (prescription drug)
- Itraconazole (prescription drug)
In randomized trials, oral and topical drugs had similar clinical cure rates, which are over 90%. Studies have shown that patients have reported a preference for oral treatment. (4)
However, topical treatments may have side effects such as local burning or irritation, while oral medication may cause nausea, vomiting, diarrhea, headaches, rash, and transient liver function abnormalities.
In addition, oral medications take a day or two longer than topical therapy to relieve symptoms.
Uncomplicated cases can be treated with either intravaginal medications or oral pills. In such cases, the choice of therapy depends on the drug interaction, cost, and patient choice.
For pregnant women with symptomatic Candida infection, topical clotrimazole or miconazole, vaginally for seven days is recommended rather than treatment with oral fluconazole because of potential risks in pregnancy. (5)
Vaginal candidiasis is not associated with adverse pregnancy outcomes. Recurrent vaginal thrush can be managed with initial fluconazole for three doses every 72 hours and then weekly oral antifungal pills for 6 months, constituting a suppressive therapy.
Boric acid (600 mg boric acid intravaginal suppositories daily for 2 weeks) can be considered in cases of proven azole-resistant infection.
Risk Factors for Vaginal Thrush
Vaginal thrush is a common infection among women of all ages, especially in their reproductive period. Certain factors can predispose a woman to develop vaginal candidiasis, including:
- Age between 20 and 40, vaginal thrush is rare in women before puberty and after menopause
- Use of hormonal contraceptives such as oral pills, IUD, or postmenopausal hormonal therapy
- Excessive stress
- Use of certain medicines such as antibiotics
- Weakened immune system, which may be due to underlying conditions (such as HIV) or medications (such as steroids and chemotherapy)
Possible Alternative Treatments for Vaginal Thrush
There is a popular belief that the intake or vaginal administration of yogurt or live lactobacilli decreases the rate of Candida infection and prevent relapse. However, this claim is not backed by strong scientific evidence.
Further research is needed to establish the efficacy of yogurt and lactobacillus in preventing and treating vaginal thrush. (6)
Some people also use coconut oil and garlic to treat vaginal thrush. However, no scientific studies support this claim.
Some studies demonstrate the efficacy of boric acid in treating vaginal yeast infection. However, it should be reserved for azole-resistant and recurrent infections especially caused by Candida glabrata species. (7)(8)(9)
Note: Gentian violet is promoted as a treatment for vaginal thrush on several commercial websites, but experts advise against its use due to the carcinogenic risk.
Self-Care Tips to Prevent Vaginal Thrush
It is necessary to maintain vaginal hygiene to prevent yeast infections. Here are a few suggestions that can help prevent vaginal thrush and manage its symptoms:
- Avoid panty liners and topical lubricants.
- Wear all-cotton underwear.
- Do not wear pantyhose (wear a thigh-high or knee-high hose instead).
- Wear loose-fitting pants or skirts.
- Remove wet bathing suits and exercise clothing promptly.
- Use dermatologically approved detergents.
- Double-rinse underwear and any other clothing that comes into contact with the vulva.
- Do not use fabric softener on undergarments.
- Use soft, white, unscented toilet paper.
- Avoid getting shampoo on the vulvar area.
- Do not use bubble bath or any perfumed creams or soaps.
- Wash the vulva with cool to lukewarm water only.
- Rinse the vulva with water after urination.
- Use 100% cotton menstrual pads and tampons.
- Use a water-based lubricant if needed during intercourse.
- Urinate (to prevent infection) and rinse the vulva with cold water after sexual intercourse.
- Avoid contraceptive creams or spermicides.
- Do not swim in highly chlorinated pools.
- Avoid the use of hot tubs.
Will Your Sexual Partner Need Treatment?
Although generally not a sexually transmitted disease, vaginal thrush can be transmitted to your partner during vaginal, anal, or oral sex. The risk of infecting your partner depends on certain factors.
Men have low chances of getting infected. However, if any of the following symptoms develop, they should consult a doctor:
- Itchy, red rash on the penis
- Irritation under the foreskin or at the tip of the penis (balanitis)
- Spotty, red rash on the tip of the penis
Complications of Vaginal Candidiasis
Vaginal candidiasis does not lead to severe complications. However, if left untreated for long, it can cause secondary infections, making the symptoms worse.
The inflammation can also spread quickly to surrounding vulvar area and groin. It can cause Candida urinary tract infections. Prolonged itching or infection due to yeast can cause chronic dermatosis and other skin conditions.
If accompanied by a weakened immune system, the inflammation may aggravate and spread, leading to severe complications.
Vaginal candidiasis is not associated with adverse pregnancy outcomes. (10)
When to Visit a Doctor
It is recommended to see your gynecologist if:
- You are experiencing symptoms of thrush.
- The infection is recurrent (more than two episodes in 6 months).
- You are pregnant or breastfeeding.
- Over-the-counter treatment is not working.
- You have lowered immune strength due to conditions such as HIV and diabetes or chemotherapy.
What you may ask your doctor:
- How long will it take for the infection to resolve?
- Is the problem contagious?
- Can it spread and infect other parts of the body?
- What steps can I take to maintain vaginal hygiene?
What your doctor may ask you:
- Are you pregnant?
- When did the symptoms first occur?
- Are you sexually active?
- Are you diabetic?
- Are you taking any medications currently?
Vaginal thrush is an infection caused by an overgrowth of yeast of the Candida species. This yeast exists naturally in the intestines and vagina. It is usually harmless, but if there is increased growth, symptoms can develop. See a doctor if your symptoms do not resolve with over-the-counter treatments. Follow preventive self-care for vulvar hygiene.