Woman's Diagnostic Cyber Disease Profile
Name: candida yeast vaginitis
Synonyms: yeast vaginitis, candidiasis, monilial vaginitis
This vaginal infection occurs predominantly in reproductive age women. The main symptoms produced by a candida yeast vaginitis are vaginal and/or vulvar itching (pruritus), or even a vulvar burning sensation. There is a cheese-like (caseous) white to white yellow discharge. Also there can be swelling of the perineum or a redness (erythema) (1). The discharge is not watery and usually not odorous. Symptoms build up over 1-3 days.
Is it common?
Yeast vaginitis is very uncommon before menarche and after menopause in the absence of taking any estrogen. This is probably because candida does not grow well in these environments (2). Even in asymptomatic, reproductive age women without recent yeast infection, there is 25-30% incidence of vaginal yeast colonization by polymerase chain reaction (PCR) and that is no different than in women who have recurrent yeast infections (3). Cultures are more often positive in women with a history of recurrent yeast infection than in asymptomatic women (22 vs 6%) which would indicate that quantitatively there are more yeast organisms in women prone to frequent infections. There is a somewhat higher incidence of yeast vaginitis among wearers of panty hose (4).
Vaginal or vulvar burning is not always a differentiating factor for yeast vaginitis compared to bacterial vaginosis for example. One study found that the best differentiating factors were: condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, and absence of current gonorrhea or bacterial vaginosis (5).
Vaginal pH is lower in yeast infections than other types of vaginitis and is usually in the range of 3.8-4.2 but almost always less than 4.5 (6).
Gram stain showing yeast is an accurate method of diagnosis as is culture but this only applies to symptomatic patients because there is a background positivity in women without yeast problems. Wet prep examination is accurate if both hyphae and spores are seen but has false negative results.
A woman can have white or yellowish discharge that is not curdy or cheese-like. There is not always itching and burning of the vulva or even redness and swelling. Cause The cause of yeast vaginitis has at least two components. One is the presence of a yeast species growing in the vagina and the other is some change in the vaginal biochemical or immune environment that allows the yeast organisms to overgrow and produce symptoms.
About 25-30% of reproductive age women have some yeast present in the vagina. The most common yeast organism is candida albicans but other species of yeast also produce symptoms such as C. glabrata, C. tropicalis, C. guilliermondii and C. parapsilosis and others (7).
The second condition needed for a vaginal yeast overgrowth is some change in the vaginal biochemistry. In the normal, non infection state, vaginal lactobacillus adhere to the epithelial wall of the vagina and prevent other uropathogens from attaching (8). As you can see, anything that alters the normal vaginal lactobacilli (such as antibiotics) will predispose a woman to vaginal infections and if yeast happens to be the pathogen present, it will begin to attach to epithelium and produce symptoms. Diabetes and any immune system suppressant will raise the incidence of diabetes; oral contraceptives do not predispose to yeast infection while pregnancy does (9). HIV patients only have increased yeast infections if their immune system is suppressed, usually with CD4 counts below 200 cells/mm3 (10).
Vaginal biopsy or tissue culture.
Natural history untreated
Yeast vaginitis can be indolent without severe symptoms or it can be quite severe. Eventually a yeast infection goes away but it always requires some sort of treatment to reduce the amount of yeast present. This may involve frequent washing or protective salves on the perineum and douching or washing out the vaginal secretions. Because the burning symptoms can be fairly intense, there are no studies of how long it takes the natural course of yeast vaginitis to run.
It is uncommon to have both yeast infection and a bacterial vaginosis (11) but it sometimes happens with recurrent bacterial vaginosis infections (12). Candida yeast infection during pregnancy is not associated with preterm labor (13).
Goals of therapy (Rx)
To reduce the number of yeast organisms and protect the vulvar tissues so that itching or rubbing will not break down the skin and lead to secondary perineal bacterial infection. The burning symptoms of the vulva are thought to be due to alcohol and other toxic products that are metabolized by the yeast from body carbohydrates. 1st choice therapy Butoconazole (Femstat®, Mycelex ) intravaginally for 3 days is the drug of choice. There are many fungal species that can be resistant to various topical treatments and the butaconazole is recommended based on some of the following studies:
- Of topical imidazoles for yeast vaginitis, butoconazole and itraconazole seem to have the best activity in the test tube against various yeasts and other fungal organisms (14, 15)
- T. glabrata and S. cerevisiae are more resistant (in vitro) to clotrimazole and ketoconazole, C. krusei strains resistance to nystatin and flucytosine have been noted. (16)
Other therapies used Terconazole (Terazole®) is a commonly used prescription therapy if over-the-counter therapy does not work. It is somewhat more effective than fluconazole (Diflucan®) for many species (17).
Boric acid vaginal suppositories at 600 mg/day for 10 days is 80% effective for C. glabrata which has been resistant to other standard therapies (18).
Essential oil therapy can also be used to treat yeast vaginitis. Tea tree oil has been shown to be effective against yeast in concentrations of 0.5% to 2% (19).
There can be resistances of the yeast species to commonly prescribed medications. One of the major causes of these resistances is due to the emergence of C. glabrata as the infectious agent rather than C. Albicans. C. glabrata is more resistance to many of the treatments (20)
Treatments to avoid
Sometimes a women may have an irritant vulvovaginitis which is not truly due to a yeast infection. Treatment creams, suppositories or even perineal pads may actually produce an allergic response or irritation that makes the problem worse. Reason for Rx
choices Vaginal topical treatment with butaconazole is the first choice treatment rather than oral fluconazole (Diflucan®) because it is non-prescription and very effective. F
luconazole is effective but non candida albicans species are becoming more resistant to it and requiring higher doses to eradicate the yeast (21, 22). The scientific feeling is to save the systemic (oral) therapy for patients who have blood-borne yeast infections such as with AIDs or associated with chemotherapy for cancer rather than inducing resistant organisms while treating only vaginal infections. Ingestion of yogurt that has live lactobacillus acidophilus does not seem to reduce the incidence of yeast vaginitis although it may play a role for bacterial vaginitis (23). References See above hyperlinks. Other resources Bacterial Vaginal Infections in Pregnancy
Signs and Symptoms of Vulvovaginal Candidiasis
Irritant Vulvitis Often Misdiagnosed as Yeast
Yeast Vaginitis - Treat the Symptoms or Diagnose by Culture?
National Vaginitis Association
Intelihealth - yeast vaginitis