Vaginal yeast infection

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Vaginal yeast infection
Other namesCandidal vulvovaginitis, vaginal thrush
Vaginal candidiasis, Gram stain.jpg
Gram stain showing the spores and pseudohyphae of Candida albicans surrounded by round vaginal skin cells, in a case of candidal vulvovaginitis.
Specialty Gynaecology
Symptoms Vaginal itching, burning with urination, white and thick vaginal discharge, pain with sex, redness around the vagina [1]
CausesExcessive growth of Candida [1]
Risk factors Antibiotics, pregnancy, diabetes, HIV/AIDS [2]
Diagnostic method Testing the vaginal discharge [1]
Differential diagnosis Chlamydia, gonorrhea, bacterial vaginosis [3] [1]
Treatment Antifungal medication [4]
Frequency75% of women at some point [1]

Vaginal yeast infection, also known as candidal vulvovaginitis and vaginal thrush, is excessive growth of yeast in the vagina that results in irritation. [5] [1] The most common symptom is vaginal itching, which may be severe. [1] Other symptoms include burning with urination, a thick, white vaginal discharge that typically does not smell bad, pain during sex, and redness around the vagina. [1] Symptoms often worsen just before a woman's period. [2]

Contents

Vaginal yeast infections are due to excessive growth of Candida . [1] These yeast are normally present in the vagina in small numbers. [1] Vaginal yeast infections are typically caused by the yeast species Candida albicans . Candida albicans is a common fungus often harbored in the mouth, digestive tract, or vagina without causing adverse symptoms. [6] The causes of excessive Candida growth are not well understood, [7] but some predisposing factors have been identified.

It is not classified as a sexually transmitted infection; however, it may occur more often in those who are frequently sexually active. [1] [2] Risk factors include taking antibiotics, pregnancy, diabetes, and HIV/AIDS. [2] Tight clothing, type of underwear, and personal hygiene do not appear to be factors. [2] Diagnosis is by testing a sample of vaginal discharge. [1] As symptoms are similar to that of the sexually transmitted infections, chlamydia and gonorrhea, testing may be recommended. [1]

Treatment is with an antifungal medication. [4] This may be either as a cream such as clotrimazole or with oral medications such as fluconazole. [4] Despite the lack of evidence, wearing cotton underwear and loose fitting clothing is often recommended as a preventive measure. [1] [2] Avoiding douching and scented hygiene products is also recommended. [1] Probiotics have not been found to be useful for active infections. [8]

Around 75% of women have at least one vaginal yeast infection at some point in their lives, while nearly half have at least two. [1] [9] Around 5% have more than three infections in a single year. [9] It is the second most common cause of vaginal inflammation after bacterial vaginosis. [3]

Signs and symptoms

Speculum exam in candidal vulvovaginitis, showing thick, curd-like plaque on the anterior vaginal wall. A slightly erythematous base is visible close to the center of the image, where some of the plaque was scraped off. Speculum exam in candidal vulvovaginitis.jpg
Speculum exam in candidal vulvovaginitis, showing thick, curd-like plaque on the anterior vaginal wall. A slightly erythematous base is visible close to the center of the image, where some of the plaque was scraped off.

The symptoms of vaginal thrush include vulval itching, vulval soreness and irritation, pain or discomfort during sexual intercourse (superficial dyspareunia), pain or discomfort during urination (dysuria) and vaginal discharge, which is usually odourless. [10] Although the vaginal discharge associated with yeast infection is often described as thick and lumpy, like paper paste or cottage cheese, it can also be thin and watery, or thick and of uniform texture. [2] In one study, women with vaginal yeast infection were no more likely to describe their discharge as cottage-cheese like than women without. [11]

As well as the above symptoms of thrush, vulvovaginal inflammation can also be present. The signs of vulvovaginal inflammation include erythema (redness) of the vagina and vulva, vaginal fissuring (cracked skin), edema (swelling from a build-up of fluid), also in severe cases, satellite lesions (sores in the surrounding area). This is rare, but may indicate the presence of another fungal condition, or the herpes simplex virus (the virus that causes genital herpes). [12]

Vaginal candidiasis can very rarely cause congenital candidiasis in newborns. [13]

Causes

Yeast infection Yeast Infection.png
Yeast infection

Medications

Infection occurs in about 30% of women who are taking a course of antibiotics by mouth. [2] Broad-spectrum antibiotics kill healthy bacteria in the vagina, such as Lactobacillus . These bacteria normally help to limit yeast colonization. [14] [15]

Oral contraceptive use is also associated with increased risk of vaginal thrush. [16] [2]

Pregnancy

In pregnancy, higher levels of estrogen make a woman more likely to develop a yeast infection. During pregnancy, the Candida fungus is more common, and recurrent infection is also more likely. [2] There is tentative evidence that treatment of asymptomatic candidal vulvovaginitis in pregnancy reduces the risk of preterm birth. [17]

Lifestyle

While infections may occur without sex, a high frequency of intercourse increases the risk. [2] Personal hygiene methods or tight-fitting clothing, such as tights and thong underwear, do not appear to increase the risk. [2]

Diseases

Those with poorly controlled diabetes have increased rates of infection while those with well controlled diabetes do not. [2] The risk of developing thrush is also increased when there is poor immune function, [12] as with HIV/AIDS, or in those receiving chemotherapy.

Diet

A diet high in sugar may increase the risk of vaginal thrush; [2] in some women, reducing sugar intake seems to reduce the risk of reoccurring vaginal thrush. [2]

Species of yeast responsible

While Candida albicans is the most common yeast species associated with vaginal thrush, infection by other types of yeast can produce similar symptoms. A Hungarian study of 370 patients with confirmed vaginal yeast infections identified the following types of infection: [18]

Non-albicans Candida are often found in complicated cases of vaginal thrush in which the first line of treatment is ineffective. These cases are more likely in those who are immunocompromised. [19]

Diagnosis

Vaginal wet mount in candidal vulvovaginitis, showing slings of pseudohyphae of Candida albicans. A chlamydospore is visible at left. Detail of vaginal wet mount in candidal vulvovaginitis.jpg
Vaginal wet mount in candidal vulvovaginitis, showing slings of pseudohyphae of Candida albicans. A chlamydospore is visible at left.

Vulvovaginal candidosis is the presence of Candida in addition to vaginal inflammation. [3] The presence of yeast alone is not sufficient, as it could be colonization (biology), part of the microbial consortium normally present in the vagina, its microbiome; the presence of yeast is typically diagnosed in one of three ways: vaginal wet mount microscopy, microbial culture, and antigen tests. [3] The results may be described as being either uncomplicated or complicated.[ citation needed ]

Uncomplicated

Uncomplicated thrush is when there are less than four episodes in a year, the symptoms are mild or moderate, it is likely caused by Candida albicans, and there are no significant host factors such as poor immune function. [20]

Complicated

Complicated thrush is four or more episodes of thrush in a year or when severe symptoms of vulvovaginal inflammation are experienced. It is also complicated if coupled with pregnancy, poorly controlled diabetes, poor immune function, or the thrush is not caused by Candida albicans. [20]

Recurrent, pathophysiology

About 5-8% of the reproductive age female population will have four or more episodes of symptomatic Candida infection per year; this condition is called recurrent vulvovaginal candidiasis (RVVC). [21] [22] Because vaginal and gut colonization with Candida is commonly seen in people with no recurrent symptoms, recurrent symptomatic infections are not simply due to the presence of Candida organisms. There is some support for the theory that RVVC results from an especially intense inflammatory reaction to colonization. Candida antigens can be presented to antigen-presenting cells, which may trigger cytokine production and activate lymphocytes and neutrophils that then cause inflammation and edema. [23] [24]

PRA1 gene (pH-regulated antigen) is strongly up-regulated during vaginal infections, which correlates with inflammation. [25]

Treatment

The following treatments are typically recommended:

Short-course topical formulations (i.e., single dose and regimens of 1–3 days) effectively treat uncomplicated candidal vulvovaginitis. The topically applied azole drugs are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80–90% of patients who complete therapy. [4]

The creams and suppositories in this regimen are oil-based and might weaken latex condoms and diaphragms. Treatment for vagina thrush using antifungal medication is ineffective in up to 20% of cases. Treatment for thrush is considered to have failed if the symptoms do not clear within 7–14 days. There are a number of reasons for treatment failure. For example, if the infection is a different kind, such as bacterial vaginosis (the most common cause of abnormal vaginal discharge), rather than thrush. [12]

Vaginal boric acid has evidence of effectiveness against non-C. albicans species. [28] [29]

Recurrent

For infrequent recurrences, the simplest and most cost-effective management is self-diagnosis and early initiation of topical therapy. [30] However, women whose condition has previously been diagnosed with candidal vulvovaginitis are not necessarily more likely to be able to diagnose themselves; therefore, any woman whose symptoms persist after using an over the counter preparation, or who has a recurrence of symptoms within two months, should be evaluated with office-based testing. [4] Unnecessary or inappropriate use of topical preparations is common and can lead to a delay in the treatment of other causes of vulvovaginitis, which can result in worse outcomes. [4]

When there are more than four recurrent episodes of candidal vulvovaginitis per year, a longer initial treatment course is recommended, such as orally administered fluconazole followed by a second and third dose 3 and 6 days later, respectively. [31]

Other treatments after more than four episodes per year, may include ten days of either oral or topical treatment followed by fluconazole orally once per week for six months. [27] About 10-15% of recurrent candidal vulvovaginitis cases are due to non-Candida albicans species. [32] Non-albicans species tend to have higher levels of resistance to fluconazole. [33] Therefore, recurrence or persistence of symptoms while on treatment indicates speciation and antifungal resistance tests to tailor antifungal treatment. [31]

Vaginal boric acid can be used against recurrent infections, both with C. albicans and with other species, although with C. albicans azoles are generally used instead. [34]

Alternative medicine

Up to 40% of women seek alternatives to treat vaginal yeast infection. [35] Example products are herbal preparations, probiotics and vaginal acidifying agents. [35] Other alternative treatment approaches include switching contraceptive, treatment of the sexual partner and gentian violet. [35] However, the effectiveness of such treatments has not received much study. [35]

Probiotics (either as pills or as yogurt) do not appear to decrease the rate of occurrence of vaginal yeast infections. [36] No benefit has been found for active infections. [8] Example probiotics purported to treat and prevent candida infections are Lactobacillus fermentum RC-14, Lactobacillus fermentum B-54, Lactobacillus rhamnosus GR-1, Lactobacillus rhamnosus GG and Lactobacillus acidophilus . [37]

There is no evidence to support the use of special cleansing diets and colonic hydrotherapy for prevention.[ medical citation needed ]

Prevention

Zinc gel can prevent reinfections. [25]

Epidemiology

The number of cases of vaginal yeast infection is not entirely clear because it is not a reportable disease and it is commonly diagnosed clinically without laboratory confirmation. [37]

Candidiasis is one of the three most common vaginal infections along with bacterial vaginosis and trichomonas. [3] About 75% of women have at least one infection in their lifetime, [2] 40%–45% will have two or more episodes, [20] and approximately 20% of women get an infection yearly. [3]

Research

Vaccines that target C. albicans are under active development. Phase 2 results published in June 2018 showed a safe and high immunogenicity of the NDV-3A vaccine candidate. [38]

Related Research Articles

<span class="mw-page-title-main">Bacterial vaginosis</span> Excessive growth of bacteria in the vagina

Bacterial vaginosis (BV) is an infection of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination may occur. Itching is uncommon. Occasionally, there may be no symptoms. Having BV approximately doubles the risk of infection by a number of sexually transmitted infections, including HIV/AIDS. It also increases the risk of early delivery among pregnant women.

<span class="mw-page-title-main">Candidiasis</span> Fungal infection due to any type of Candida

Candidiasis is a fungal infection due to any species of the genus Candida. When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the mouth and throat. Other symptoms may include soreness and problems swallowing. When it affects the vagina, it may be referred to as a yeast infection or thrush. Signs and symptoms include genital itching, burning, and sometimes a white "cottage cheese-like" discharge from the vagina. Yeast infections of the penis are less common and typically present with an itchy rash. Very rarely, yeast infections may become invasive, spreading to other parts of the body. This may result in fevers, among other symptoms.

<i>Lactobacillus</i> Genus of bacteria

Lactobacillus is a genus of gram-positive, aerotolerant anaerobes or microaerophilic, rod-shaped, non-spore-forming bacteria. Until 2020, the genus Lactobacillus comprised over 260 phylogenetically, ecologically, and metabolically diverse species; a taxonomic revision of the genus assigned lactobacilli to 25 genera.

Vaginitis, also known as vulvovaginitis, is inflammation of the vagina and vulva. Symptoms may include itching, burning, pain, discharge, and a bad smell. Certain types of vaginitis may result in complications during pregnancy.

<i>Candida albicans</i> Species of fungus

Candida albicans is an opportunistic pathogenic yeast that is a common member of the human gut flora. It can also survive outside the human body. It is detected in the gastrointestinal tract and mouth in 40–60% of healthy adults. It is usually a commensal organism, but it can become pathogenic in immunocompromised individuals under a variety of conditions. It is one of the few species of the genus Candida that cause the human infection candidiasis, which results from an overgrowth of the fungus. Candidiasis is, for example, often observed in HIV-infected patients. C. albicans is the most common fungal species isolated from biofilms either formed on (permanent) implanted medical devices or on human tissue. C. albicans, C. tropicalis, C. parapsilosis, and C. glabrata are together responsible for 50–90% of all cases of candidiasis in humans. A mortality rate of 40% has been reported for patients with systemic candidiasis due to C. albicans. By one estimate, invasive candidiasis contracted in a hospital causes 2,800 to 11,200 deaths yearly in the US. Nevertheless, these numbers may not truly reflect the true extent of damage this organism causes, given new studies indicating that C. albicans can cross the blood–brain barrier in mice.

<span class="mw-page-title-main">Fluconazole</span> Antifungal medication

Fluconazole is an antifungal medication used for a number of fungal infections. This includes candidiasis, blastomycosis, coccidioidomycosis, cryptococcosis, histoplasmosis, dermatophytosis, and tinea versicolor. It is also used to prevent candidiasis in those who are at high risk such as following organ transplantation, low birth weight babies, and those with low blood neutrophil counts. It is given either by mouth or by injection into a vein.

<span class="mw-page-title-main">Oral candidiasis</span> Fungal infection

Oral candidiasis (Acute pseudomembranous candidiasis), also known as oral thrush among other names, is candidiasis that occurs in the mouth. That is, oral candidiasis is a mycosis (yeast/fungal infection) of Candida species on the mucous membranes of the mouth.

<span class="mw-page-title-main">Fungal infection</span> Disease caused by fungi to animals or humans

Fungal infection, also known as mycosis, is a disease caused by fungi. Different types are traditionally divided according to the part of the body affected; superficial, subcutaneous, and systemic. Superficial fungal infections include common tinea of the skin, such as tinea of the body, groin, hands, feet and beard, and yeast infections such as pityriasis versicolor. Subcutaneous types include eumycetoma and chromoblastomycosis, which generally affect tissues in and beneath the skin. Systemic fungal infections are more serious and include cryptococcosis, histoplasmosis, pneumocystis pneumonia, aspergillosis and mucormycosis. Signs and symptoms range widely. There is usually a rash with superficial infection. Fungal infection within the skin or under the skin may present with a lump and skin changes. Pneumonia-like symptoms or meningitis may occur with a deeper or systemic infection.

<span class="mw-page-title-main">Terconazole</span> Chemical compound

Terconazole is an antifungal drug used to treat vaginal yeast infection. It comes as a lotion or a suppository and disrupts the biosynthesis of fats in a yeast cell. It has a relatively broad spectrum compared to azole compounds but not triazole compounds. Testing shows that it is a suitable compound for prophylaxis for those that suffer from chronic vulvovaginal candidiasis.

<span class="mw-page-title-main">Fungemia</span> Internal, blood-borne infection by fungi, including yeasts.

Fungemia is the presence of fungi or yeast in the blood. The most common type, also known as candidemia, candedemia, or systemic candidiasis, is caused by Candida species. Candidemia is also among the most common bloodstream infections of any kind. Infections by other fungi, including Saccharomyces, Aspergillus and Cryptococcus, are also called fungemia. It is most commonly seen in immunosuppressed or immunocompromised patients with severe neutropenia, cancer patients, or in patients with intravenous catheters. It has been suggested that otherwise immunocompetent patients taking infliximab may also be at a higher risk.

<span class="mw-page-title-main">Vaginal discharge</span> Medical condition

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amount, and quality of discharge varies between individuals and can vary throughout the menstrual cycle and throughout the stages of sexual and reproductive development. Normal vaginal discharge may have a thin, watery consistency or a thick, sticky consistency, and it may be clear or white in color. Normal vaginal discharge may be large in volume but typically does not have a strong odor, nor is it typically associated with itching or pain. While most discharge is considered physiologic or represents normal functioning of the body, some changes in discharge can reflect infection or other pathological processes. Infections that may cause changes in vaginal discharge include vaginal yeast infections, bacterial vaginosis, and sexually transmitted infections. The characteristics of abnormal vaginal discharge vary depending on the cause, but common features include a change in color, a foul odor, and associated symptoms such as itching, burning, pelvic pain, or pain during sexual intercourse.

<i>Nakaseomyces glabratus</i> Species of fungus

Nakaseomyces glabratus is a species of haploid yeast of the genus Nakaseomyces, previously known as Candida glabrata. Despite the fact that no sexual life cycle has been documented for this species, N. glabratus strains of both mating types are commonly found. N. glabrata is generally a commensal of human mucosal tissues, but in today's era of wider human immunodeficiency from various causes, N. glabratus is often the second or third most common cause of candidiasis as an opportunistic pathogen. Infections caused by N. glabratus can affect the urogenital tract or even cause systemic infections by entrance of the fungal cells in the bloodstream (Candidemia), especially prevalent in immunocompromised patients.

<span class="mw-page-title-main">Esophageal candidiasis</span> Medical condition

Esophageal candidiasis is an opportunistic infection of the esophagus by Candida albicans. The disease usually occurs in patients in immunocompromised states, including post-chemotherapy and in AIDS. However, it can also occur in patients with no predisposing risk factors, and is more likely to be asymptomatic in those patients. It is also known as candidal esophagitis or monilial esophagitis.

<span class="mw-page-title-main">Clotrimazole</span> Chemical compound

Clotrimazole, sold under the brand name Lotrimin, among others, is an antifungal medication. It is used to treat vaginal yeast infections, oral thrush, diaper rash, tinea versicolor, and types of ringworm including athlete's foot and jock itch. It can be taken by mouth or applied as a cream to the skin or in the vagina.

Invasive candidiasis is an infection (candidiasis) that can be caused by various species of Candida yeast. Unlike Candida infections of the mouth and throat or vagina, invasive candidiasis is a serious, progressive, and potentially fatal infection that can affect the blood (fungemia), heart, brain, eyes, bones, and other parts of the body.

<i>Candida tropicalis</i> Species of fungus

Candida tropicalis is a species of yeast in the genus Candida. It is a common pathogen in neutropenic hosts, in whom it may spread through the bloodstream to peripheral organs. For invasive disease, treatments include amphotericin B, echinocandins, or extended-spectrum triazole antifungals.

<span class="mw-page-title-main">Ibrexafungerp</span> Medication

Ibrexafungerp, sold under the brand name Brexafemme, is an antifungal medication used to treat vulvovaginal candidiasis (VVC). It is taken orally. It is also currently undergoing clinical trials for other indications via an intravenous (IV) formulation. An estimated 75% of women will have at least one episode of VVC and 40 to 45% will have two or more episodes in their lifetime.

<span class="mw-page-title-main">Oteseconazole</span> Chemical compound

Oteseconazole, a novel orally bioavailable and selective inhibitor of fungal cytochrome P450 enzyme 51 (CYP51), has shown promising efficacy in the treatment of recurrent vulvovaginal candidiasis (RVVC) in patients.

<span class="mw-page-title-main">TOL-463</span> Combination drug

TOL-463 is an anti-infective medication which is under development for the treatment of bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC). It is a boric acid-based vaginal anti-infective enhanced with ethylenediaminetetraacetic acid (EDTA) which was designed to have improved activity against vaginal bacterial and fungal biofilms while sparing protective lactobacilli. EDTA enhances the antimicrobial activity of boric acid and improves its efficacy against relevant biofilms. In a small phase 2 randomized controlled trial, TOL-463 as an insert or gel achieved clinical cure rates of 50–59% against BV and 81–92% against VVC in women who had one or both conditions. It was effective and safe in the study, though it was without indication of superiority over other antifungal medications for VVC. The cure rates against BV with TOL-463 were said to be comparable to those with recently approved antibiotic treatments like single-dose oral secnidazole (58%) and single-dose metronidazole vaginal gel (41%). As of May 2019, TOL-463 is in phase 2 clinical trials for the treatment of BV and VVC. It was originated by Toltec Pharmaceuticals and is under development by Toltec Pharmaceuticals and the National Institute of Allergy and Infectious Diseases.

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