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Candidal vulvovaginitis or vaginal thrush is an infection of the vagina’s mucous membranes by Candida albicans. Up to 75% of women will have this infection at some point in their lives, and approximately 5% will have recurring episodes. It is the second most common cause of vaginal inflammation after bacterial vaginosis.
It is most commonly caused by a type of fungus known as Candida albicans. The Candida species of fungus is found naturally in the vagina, and is usually harmless. However, if the conditions in the vagina change, Candida albicans can cause the symptoms of thrush. Symptoms of thrush can also be caused by Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis. Non-albican Candida are commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective. These cases are more likely in immunocompromised patients.
It is not known exactly how changes in the vagina trigger thrush, but it may be due to a hormone (chemical) imbalance. In most cases, the cause of the hormonal changes is unknown. Some possible risk factors have been identified, such as taking antibiotics.
Signs and symptoms
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. This can be thin and watery, or thick and white, like cottage cheese.
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, vagina 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).
In pregnancy, changes in the levels of female sex hormones, such as estrogen, make a woman more likely to develop a yeast infection. During pregnancy, the Candida fungus is more prevalent (common), and recurrent infection is also more likely. There is no clear evidence that treatment of asymptomatic candidal vulvovaginitis in pregnancy reduces the risk of preterm birth.
Infections often occur without sex and cannot be related to frequency of intercourse. Tight-fitting clothing, such as tights and thong underwear, do not appear to increase the risk. Neither do personal hygiene methods.
The risk of developing thrush is also increased in an immunodeficiency, for example, by an immunosuppressive condition, such as HIV or AIDS, or receiving chemotherapy. This is because in these circumstances the body's immune system, which usually fights off infection, is unable to effectively control the spread of the Candida fungus.
Vulvovaginal candidosis is the presence of Candida in addition to vaginal inflammation. The presence of yeast is typically diagnosed in one of three ways: microscopy, microbial culture, and antigen tests. It may be described as being uncomplicated or complicated.
Uncomplicated thrush is where only a single episode of thrush or less than four episodes occurs in a year. Thrush is described as uncomplicated if the symptoms are mild or moderate, and caused by the Candida albicans fungus.
Complicated thrush is four or more episodes of thrush in a year or when severe symptoms of vulvovaginal inflammation are experienced. Thrush may also be described as complicated if coupled with pregnancy, poorly controlled diabetes, an immune deficiency, or the thrush is not caused by the Candida albicans fungus.
Following are alternatives of recommended regimens:
- Intravaginal agents: butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole. Candidal vulvovaginitis in pregnancy should be treated with intravaginal clotrimazole or miconazole for at least 7 days.
- Oral Agent: fluconazole as a single dose.
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.
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.
For infrequent recurrences, the simplest and most cost-effective management is self-diagnosis and early initiation of topical therapy. 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 2 months, should be evaluated with office-based testing. Unnecessary or inappropriate use of OTC preparations is common and can lead to a delay in the treatment of other vulvovaginitis etiologies, which can result in adverse clinical outcomes.
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. Preventive maintenance treatment may be recommended after more than four episodes per year, such as by fluconazole orally once per week for 6 months. Recurrence or persistence of symptoms while on treatment indicates speciation and antifungal resistance tests to tailor antifungal treatment.
There is not enough evidence to determine if probiotics (either as pills or as yogurt) has an effect on the rate of occurrence of vaginal yeast infections. No benefit has been found for active infections.
Candidiasis is one of the three most common vaginal infections along with bacterial vaginosis and trichomonas. Approximately 20% of women get an infection yearly. It is believed that 70–75% of women have at least one infection in their lifetime.
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