Vaginal Thrush

Many women have an occasional bout of vaginal thrush. It is due to an infection with types of fungal yeast called Candida spp. Treatment options include a tablet that you can take by mouth, or anti-thrush pessaries that you can insert into the vagina. There is also anti-thrush cream that you can rub on to the skin around the vagina (the vulva) if needed. Treatment usually works well. However, some women have recurring bouts of thrush which may need longer courses of treatment.

What is thrush?

Thrush is an infection caused by types of fungal yeast 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 germs (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., its number 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 causes of thrush are a result of 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.

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 womb. If you are pregnant, thrush will not harm your baby.

Who gets vaginal thrush?

More than half of all women will have at least one bout of thrush in their lives. In most cases, it develops for no apparent reason. However, certain factors can make thrush more likely to develop. The vagina contains mucus and some harmless germs (bacteria) which help to defend the vagina from candidal infection (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 antibiotic medication. So, in these situations, you may be more likely to develop thrush.

People with a poor immune system are also more likely to develop thrush – for example, people on chemotherapy for certain cancers, people taking high-dose steroids, etc.

Some women develop repeated (recurrent) thrush. Recurrent thrush is defined as a bout of thrush four or more times in a year. Of women who develop a first bout of vaginal thrush, about five in 100 of them will get problems with recurrent vaginal thrush. In most cases, the reason why this occurs is not known. Some women just seem more prone than usual to develop thrush. However, women with uncontrolled diabetes and women with a poor immune system may be more likely to develop recurrent thrush.

There is some debate as to whether women taking hormone replacement therapy or the oral contraceptive pill are more likely to develop recurrent thrush – the evidence is not yet clear.

Do I need any tests?

You do not always need a test to diagnose thrush. The diagnosis is often based on the typical symptoms and signs. However, it is important that you do not assume that a vaginal discharge is thrush. There are other causes of vaginal discharge. If you have never had thrush before then see a doctor or nurse to confirm the diagnosis and for advice on treatment. The doctor or nurse may examine you. No tests may be necessary if the symptoms and signs are typical.

However, the doctor or nurse may take small samples of the discharge with swabs if the cause of the discharge is not clear. A swab is a small ball of cotton wool on the end of a thin stick. The swabs are then sent to the laboratory to confirm the cause of the discharge.

If you have had thrush in the past and the same symptoms return (recur) then it is common practice to treat it without further examination or tests. If symptoms are not typical or the same as you usually have, or if you are having recurring symptoms, your doctor or nurse may examine you and take some swabs to confirm the cause.

Also, the doctor or nurse may check a urine sample if you have recurring thrush, to rule out

To be continued next week

What are the treatment options for vaginal thrush?

Topical thrush treatments

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. In severe infection, you may be advised to use a second pessary after three days.

You can obtain topical treatments on prescription, or you can buy them without a prescription at pharmacies. 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 always check with your doctor or pharmacist. Treatment is usually needed for longer during pregnancy.

Note: some pessaries and creams may damage latex condoms and diaphragms and affect their use as a contraceptive. You should use alternative methods of contraception during treatment and for several days afterwards.

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 obtain 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. Combination packs containing both the tablet and cream are available. In severe infection, a repeat dose of the tablet may be suggested after three days.

Note: tablets and topical treatments are thought to be equally effective. Tablets are more convenient, but are more expensive than most topical treatments.

Other things that may help

If you have thrush, you may also find the following things help to relieve your symptoms:

• Avoiding wearing tight-fitting clothing, especially clothing made from synthetic materials. Loose-fitting, natural fibre underwear may be better.
• Avoiding washing underwear with biological washing powders or liquids and avoiding the use of fabric conditioners.
• Avoiding using perfumed products around the vaginal area, such as soaps and shower gels, as these may cause further irritation.
• Using a simple emollient every day as a moisturiser to protect the skin around the vulva.

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 (samples taken using a small ball of cotton wool on the end of a thin stick) to clarify the cause of the symptoms.
• Most bouts of thrush are caused by C. albicans. However, about 1 in 10 bouts of thrush are caused by other strains of Candida spp., such as C. 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 antibiotic medication, or if you have undiagnosed or poorly controlled diabetes.)

Do I need to see a doctor if I get vaginal thrush?

If you have had thrush in the past and the same symptoms return (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.
• Have lower tummy (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 after treatment.

What can I do to prevent vaginal thrush returning (recurring)?

The following tips may help. However, they have not been proven to work by research. 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 rinsing out (douching) of the vagina, bubble baths, scented soaps, spermicides, etc. The normal mucus and germs (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.

Antibiotic medicines. 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. are yeasts and not bacteria, they 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 treatment 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.

What is the treatment for repeated (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 develop the occasional bout again. However, some women return to developing 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.
• If you have recurrent thrush, your doctor or nurse may also discuss your current method of contraception with you and suggest a change. There has been talk in the past about the combined oral contraceptive pill (the pill that contains both oestrogen and progesterone hormones) possibly making recurrent thrush more likely. However, the evidence around this is a little contradictory. One study has shown that woman who use the progestogen-only contraceptive injection may be less likely to develop thrush.

Some other points about vaginal thrush

• ‘Natural’ remedies for thrush include: live yoghurt inserted into the vagina or adding vinegar or bicarbonate of soda to a bath to alter the acidity of the vagina. 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. are yeast germs (bacteria) which commonly occur on the skin and vagina. For reasons not quite clear, they sometimes multiply 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.
• Thrush occurs more commonly in pregnant women, and can be more difficult to clear. If you are pregnant, a course of seven days of topical treatment is usually advised to clear thrush.