Chronic Recurrent Yeast Vaginitis - What Can Be Done?
Frederick R. Jelovsek MD
"How do you get rid of recurrences of yeast infections? This is a constant thing every month. I need help. I don't have sugar. I have been tested for that as well as thyroid. I am 39 years old and I have been to several doctors and so far I haven't been able to shake this infection completely. What other doctor should I go to besides a Gyn physician? ". T.J.
Chronic yeast infections can be very annoying. The symptoms are vaginal discharge with vulvar itching and burning which occurs 4 or more times a year. These symptoms can also be a sign of irritant vulvitis so it is important to confirm the diagnosis of recurrent yeast infection.
The diagnosis can be confirmed by seeing yeast on a wet prep of the vagina, or by growing candida yeast species on culture. This should be performed for several recurrences in a row, otherwise the condition can easily be an irritant vaginitis which will not respond to anti-yeast treatment. Remember that most episodes of vaginal burning that are assumed to be recurrent yeast infections are really irritant vulvitis due to
- propylene glycol
- butylated hydroxyanisol (BHA)
- cetyl alcohol
- sodium lauryl sulfate
- methyl benzethonium chloride
which are present in creams, lubricants, spermicides, scented sanitary products, douches, soaps, bubble baths and condom lubricants (1). There are also many other vulvar dermatoses that can present with vulvar burning (2).
If the vaginitis always occurs around the time of menses and if you get irritation high up on the mons pubis, the area of skin and fat above the clitoris, and you use sanitary pads, then you should strongly suspect that your symptoms are due to an allergic or sensitivity reaction to the pads themselves rather than a yeast vulvitis (3).
Common Questions About Chronic Yeast Infections
What are risk factors for chronic recurrent yeast infections?
Diabetes and abnormal glucose tolerance or insulin resistance are major risk factors for recurrent yeast infections but fortunately you have stated that your testing was negative for this. Oral contraceptives are also a risk factor (4). Patients infected with HIV are only at risk if their CD4 counts are less than 100 (5). Chronic antibiotic therapy can also be a risk factor for recurrent yeast infections. As long as you do not have any of these conditions, you should be able to get cleared up of the chronic recurrences of yeast.
Are resistant yeast strains a common cause of recurrent yeast infections?
In the long run, drug resistance of candida yeast strains presents a problem in that drugs are only effective for periods of years rather than for decades or forever. For an individual woman, however, it does not appear that resistance to drugs is the main reason for chronic recurrences (6). The same strain of candida is often the etiology of the recurrent infection although sometimes the there is a change in the subspecies of candida from one infection to another (7).
This is not to say that drug resistance can not play a role in recurrent yeast infections. In fact up to 10% of recurrent yeast infections can be due to a different yeast strain called torulopsis glabrata (now renamed candida glabrata) (8). This yeast strain is commonly resistant to many of the standard topical treatments as well as to oral fluconazole (DIflucan ®) (9, 10).
What are the best treatments for recurrent candida yeast infection?
Butoconazole may be more effective than other anti-yeast treatments against non-candida albicans which are more often resistant to fluconazole (DIflucan ®) and terconazole (Terazole ®) (11). Since this topical treatment is available without prescription, it is a good agent to use for chronic recurrences. Boric acid vaginal suppositories can also be effective against both candida albicans and candida glabrata (12).
Can these episodes of infections be prevented?
Weekly treatment with a terconazole vaginal cream (Terazol®) decreases episodes of yeast vaginitis (13). Yogurt with lactobacillus acidophillus cultures does not seem to decrease episodes of yeast vaginitis although it may somewhat reduce episodes of bacterial vaginitis (14).Although in practice, many physicians have been prescribing weekly fluconazol (Diflucan ®) 150 mg by mouth, there have not as yet been studies showing whether this is an effective approach. It would seem that some sort of periodic treatment either weekly or monthly with either intravaginally or oral medication would be the best approach to prevent recurrences.
There are also several living habits and bodily care changes that are felt to help prevent vulvar skin irritation so that a secondary yeast vulvitis (as opposed to a primary yeast vaginitis) does not develop.
- Avoid pantyhose and tight pants such as jeans which trap moisture near the perineum
- After exercise or any sweat producing activity, bathing or swimming, make sure the perineum is air dryed. Moist surfaces that rub against each other break down and provide an area for yeast secondary growth
- Wear loose, all cotton underwear (not cotton crotch panties) that absorbs body moisture.
- Wipe front to back when you urinate or have a bowel movement. Bowel bacteria and yeast can cause vulvar skin breakdown and vaginal infection.
- Use tampons instead of sanitary pads. The chemicals in many pads can cause perineal skin irritation. Natural cotton pads that you launder in hypo allergenic detergent are alright to use.
- Do not shave the vulvar area. The pubic hair protects against chemicals making contact with the skin.
- Avoid all chemicals in the Vulvovaginal area.
- Follow a low carbohydrate diet with almost no simple carbohydrates, only a small amount of complex carbohydrates.
- Take steroids, antibiotics and oral contraceptives only if absolutely necessary.
What is the best work-up and management for chronic yeast infections?
If a woman suspects she is having recurrent vaginal yeast infections, the first step is to keep a record or diary of of the events for the 48 hours preceding the occurrence of vaginal discharge or vulvar irritation. During the 3rd or 4th episode within a year, go to the physician and ask to have a microscopic exam for yeast or vaginal culture for yeast. The diagnosis needs to be confirmed before embarking on a long term treatment. If you do not have confidence in your gynecologist to be receptive to these requests, try a dermatologist. They often treat vulvar dermatoses including yeast vulvitis.
Once it has been confirmed that the problem is primary yeast infection recurrence, then a treatment program can be begun. Basically you must determine the regularity with which infections occur or the preceding events that predispose to an infection. Then start a prophylactic regimen of one dose on just a slightly less frequency than the occurrences or to immediately follow an event that seems to predispose to the infection. In other words if the infections seem to occur monthly after the menses, then using an anti-yeast treatment just before or during the menses would be the best strategy. If the yeast episodes always seem to occur after a week of carbohydrate binging, a course of antibiotics or a burst of steroids for another medical problem, then use the anti-yeast treatment. right at the end of the inciting episode before it gets going.
Candidates to use for prophylactic treatment for yeast vaginitis prevention include:
- terconazole (Terazole ®) vaginal cream (15) or suppository one application each week.
- fluconazole (Diflucan ®) 150 mg orally each week or month.
- boric acid vaginal suppositories (16), one each week or month
- tea tree oil vaginal suppositories (concentrations of 0.5% to 2%) (17 ) used once a week or month