Patient information: Vaginal yeast infection

INTRODUCTION

Vaginal yeast infections are a common problem in women. It is difficult to know the true percentage of women affected by yeast infections because they are frequently diagnosed without an examination. In addition, many women treat themselves with over-the-counter yeast treatments before seeking medical advice.

Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.

Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.

VAGINAL YEAST INFECTION SYMPTOMS

Itching of the vulva is the most common symptom of a vaginal yeast infection (figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), although it may be thin and watery in some cases.

Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (table 1). (See "Patient information: Vaginal discharge in adults".)

It is often not possible to know, based on symptoms alone, if itching is caused by yeast or other potential causes. (See 'Self-diagnosis' below.)

VAGINAL YEAST INFECTION CAUSE

Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the symptoms described above.

Candida albicans causes most episodes of vulvovaginal candidiasis. Other Candida species can also cause vaginal yeast infections.

VAGINAL YEAST INFECTION RISK FACTORS

In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including:

• Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics.
• Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use birth control methods containing estrogen. (See "Patient information: Hormonal methods of birth control".)

• Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Birth control; which method is right for me?".)

• Immunosuppression — Yeast infections are more common in people who have a weakened immune system due to infection with HIV or use of certain medications (steroids, chemotherapy, post-organ transplant medications).
• Pregnancy — Vaginal discharge can become more noticeable during pregnancy, although yeast infection may not always be the cause. (See "Patient information: Vaginal discharge in adults".)

• Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are persistently higher than normal.
• Sexual activity — Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but they may develop more frequently in women who receive oral sex.

VAGINAL YEAST INFECTION DIAGNOSIS

Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing.

A physical examination is the most accurate way of determining the cause of abnormal vaginal discharge. Do not begin treatment at home before being examined because self-treatment can make it more difficult to make an accurate diagnosis.

During the examination, the healthcare provider will examine the entire outer genital area and will perform an internal examination. He/she will take a sample of the discharge to test for infection (picture 1).

Further testing with a yeast culture may be used for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful for women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if less common species of yeast are present.

Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].

Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.

VAGINAL YEAST INFECTION TREATMENT

Treatment of a vaginal yeast infection may include a pill that is taken by mouth or a vaginal treatment.

Vaginal treatment — Treatment of vaginal yeast infection may include a vaginal cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven-day treatments are equally effective.

Oral treatment — Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose.

Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole is not usually recommended during the first trimester of pregnancy due to the potential risk of harm to the fetus.

When will I feel better? — Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days. However, the vulvar and vaginal irritation can persist for up to 2 weeks.

Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined.

RECURRENT VAGINAL YEAST INFECTIONS

Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.

There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.

Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are caused by yeast rather than other common problems (eg, other vaginal infections, allergic reaction or sensitivity, eczema). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.

Treatment — Women with recurrent infections are usually given a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second and third dose 3 and 6 days later.

Preventive treatment may be recommended after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).

Treatment of a sexual partner — Vaginal yeast infections are not a sexually transmitted infection, although the infection may rarely be passed from one partner to another. Most experts do not recommend treatment of a sexual partner.

SUMMARY

• Vaginal yeast infections are a common problem in women.
• Itching is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like) or thin and watery.
• Symptoms of a yeast infection are similar to a number of other conditions (table 1). A physical examination is needed to determine the cause of symptoms.
• There are several risk factors that may increase the chances of developing a yeast infection, including use of antibiotics, birth control, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications).
• To diagnose a vaginal yeast infection, a healthcare provider will do an examination. It is important to be seen when symptoms are bothersome and before any treatment is used.
• Do not begin treatment for a yeast infection before being examined.
• Treatment of vaginal yeast infection may include a vaginal cream or tablet or a pill taken by mouth.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Vaginal discharge in adults
Patient information: Hormonal methods of birth control
Patient information: Birth control; which method is right for me?

Professional Level Information:
Candida vulvovaginitis
Chronic and acute causes of vaginal discharge other than bacterial vaginosis, candidiasis, or trichomoniasis
Clinical manifestations and diagnosis of localized, provoked vulvodynia (vestibulodynia)
Diagnostic approach to women with vaginal discharge or vulvovaginal symptoms
Differential diagnosis of vulvar lesions
Dysuria in adult women
HIV and women
Overview of Candida infections
Screening for sexually transmitted diseases

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/yeastinfections.html)

• US Department of Health and Human Services

      (www.4women.gov/faq/yeastinfect.htm)

• The Nemours Foundations

      (www.kidshealth.org/teen/infections/fungal/yeast_infections.html)

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