Vulvovaginal (VV) infections are a common and often recurrent presentation in general practice. In the ﬁrst of a two-part feature on VV infections, GP and women’s health specialist Louise Newson focuses on candidiasis (thrush) and discusses the management options in cases of recurrent or severe cases. Part 2 will focus on bacterial vaginosis.
Dr Louise R Newson GP, Shirley Medical Practice, Solihull, West Midlands
Mrs R G is a 34 year old lady who presents to her GP complaining of discharge and vulval irritation. She remembers having thrush ﬁve years ago when she was pregnant and she feels that her symptoms are similar to then.
However, she is convinced that her husband is having an affair so she is worried she has a sexually transmitted infection. She has used some clotrimazole cream she bought from the chemist but although this initially helped her symptoms she says that they have now recurred.
She is otherwise ﬁt and well and has been taking microgynon for contraception over the past year.
Vulvovaginal candidiasis (VVC, or thrush) is a symptomatic inflammation of the vagina and/or vulva caused by a superficial fungal infection – most commonly Candida albicans . 90% of cases of thrush are due to Candida albicans . Around one in twenty cases are due to Candida glabrata .
Other fungal infections of the vagina are caused by Saccharomyces cerevisiae (brewer’s yeast) and, rarely, Trichosporon spp . Unlike Candida spp , these are not usually present in the normal vaginal flora.
Although thrush is not a sexually transmitted infection (STI), it can be passed on to a sexual partner.
- Predisposing factors for thrush may include:
- Diabetes mellitus
- Disturbance of vaginal flora, i.e. with broad-spectrum antibiotics
- Oral contraceptive pill and hormone replacement therapy (oestrogen causes the lining of the vagina to mature and to contain glycogen, a substrate on which Candida albicans thrives)
- Use of scented cleansing products
- Tampons and wearing nylon tights
Some women are more prone to developing thrush than others even without any obvious predisposing conditions.
Making a diagnosis
A detailed history is very important and should include sexual history, contraceptive use, treatments tried (including OTC) and responses and whether there have been any new allergens.1
All women have a natural vaginal discharge. The discharge in women with thrush is usually thick and white – often described as “cottage cheese- like” – and does not usually smell. In some women, the discharge may become quite heavy and can lead to severe vulval itching. The vulva may become inflamed and swollen. Sexual intercourse can be very uncomfortable and dysuria may occur.
Signs of vaginal candidiasis include:
- discharge – may be thin or curdy
- satellite lesions
Note: Around 10-20% of women of reproductive age may be colonised with candida without any symptoms or signs. These women do not need any treatment.
Differential diagnoses may include bacterial vaginosis, dermatitis, allergic reactions, herpes simplex infection and lichen sclerosis. A proportion of women with vulvovaginal candidiasis also have other infections, for example chlamydia or gonorrhoea.
It is very important that women do not wrongly self - diagnose vulvovaginal candidiasis. They are equally or more likely to have bacterial vaginosis (BV), with or without VVC.
Investigations are not always needed in primary care as empirical treatment can be considered based on the history. 3 Women should have vaginal swabs taken if they are having recurrent symptoms. Self- taken swabs can be useful in obtaining culture evidence of recurrent/persistent VVC. The pH is normal in candida infections.
If thrush recurs in patients who have already had documented evidence of thrush and the symptoms are the same, then repeat swabs are usually not necessary to confirm infection.
Thrush can be treated with either topical or systemic treatment (See Table 1). Antifungal creams or pessaries can be inserted high into the vagina (including during menstruation). A soft gel clotrimazole pessary has recently been introduced which is an alternative to the tablet pessary. The soft gel pessary has been designed to be softer and more comfortable to insert than the square tablets, which can sometimes leave a chalky white residue on the underwear.
The creams are preferable for external symptoms. However, the choice of preparation is usually down to the woman’s individual preference. These are often given in combination and many are available from the chemist without a prescription.
All topical and oral azole treatments provide a clinical and mycological cure rate of over 80%. 2 Topical treatments can however cause vulvovaginal irritation, which should be considered if symptoms worsen following treatment. Patients should also be warned that topical antifungal preparations may damage latex condoms and diaphragms.
Oral antifungals include fluconazole and itraconazole. Transient, mild-to-moderate elevations in serum aminotransferase levels occur in 1% to 5% of patients on either medication. These elevations are largely asymptomatic and self-limited, and usually resolve even with continuation of therapy. Clinically apparent hepatotoxicity is rare. Fluconazole is less frequently associated with hepatotoxicity. One study demonstrated that the rate of serious adverse liver events with itraconazole was 3.2/100,000 prescriptions and with fluconazole was 1.4/100,000 prescriptions. 5
Oral ketoconazole is no longer available, as the risk of hepatotoxicity associated with oral ketoconazole is greater than the benefit when treating fungal infections.
A single tablet of fluconazole is available over the counter from pharmacists. Treatment can be repeated if the initial course fails to control symptoms or if symptoms recur. Patients do not need to be followed up if their symptoms resolve and do not need any further investigations to test whether they are cured.
Patients should be offered screening for STIs if they are at risk.
Management of complicated vulvovaginal candidiasis
Vulvovaginal candidiasis in pregnancy
VVC is very common in pregnancy, affecting 30-40% of pregnant women. However, asymptomatic women do not need to be treated. Vulvovaginal candidiasis in pregnancy is not associated with any perinatal complications, including low birth weight or premature delivery.
There is no evidence to support the use of one imidazole over another. A longer duration of treatment during pregnancy, usually seven days, is needed to clear the infection. Oral antifungals should not be given to pregnant women.
Severe vulvovaginal candidiasis
Women with severe symptoms should receive additional treatment. The treatment should be repeated after three days, e.g. oral fluconazole 150mg day 0 and day 3, or vaginal clotrimazole 500mg day 0 and day 3. 1 The addition of low potency topical steroids should be considered to improve symptoms.
Recurrent vulvovaginal candidiasis Recurrent vulvovaginal candidiasis (RVVC) is defined as four or more episodes in a year, with at least partial resolution of symptoms between episodes. RVVC is very common; around one in twenty women of reproductive age with a primary episode of VVC will develop recurrent disease.
Consideration should be given for any predisposing factors for recurrent infection and relevant investigations should be undertaken, if necessary (e.g. fasting glucose, HIV test). There is no evidence that iron deficiency is implicated in the pathogenesis of RVVC.
The British Association for Sexual Health and HIV guidelines state that positive microscopy or a moderate or heavy growth of C. albicans should be documented on at least two occasions to confirm RVVC. 1
Treatment of RVVC aims to control rather than cure the infection. The following measures may be useful:
- Avoid using bubble baths and spermicides, as these may alter the normal vaginal flora
- Emollients should be used instead of soaps
- Avoid nylon underwear or tight-fitting jeans
- Women prone to thrush after taking antibiotics may find it useful to have antifungal treatment prescribed
- Friction during intercourse may cause minor damage to the vaginal wall, which may make candida more likely to thrive. Some women may be advised to use a lubricant.
If sexual intercourse takes place when one or both partners has thrush then they should be advised to use a condom to prevent reinfection. If the woman’s partner is symptomatic, then they should be treated with a topical imidazole cream at the same time.
Any reversible predisposing factors for RVVC need to be eliminated. However, in most women with RVVC, no underlying or predisposing factor is identified.
A longer duration of initial treatment should be given followed by maintenance treatment. These regimes should not be given to pregnant women.
SOME COMMONLY USED REGIMENS INCLUDE: 1,4
- Initially oral ﬂuconazole (150mg) every three days for three doses followed by one dose every week for six months
- Initially intravaginal topical imidazole for 10-14 days followed by clotrimazole vaginally (500mg pessary) once every week for six months
- Initially intravaginal topical imidazole for 10-14 days twice a week followed by itraconazole orally (50-100mg/day) for six months
These are unlicensed uses
The first regimen results in around 90% remission at six months and around 40% at one year. 1 These regimens can be repeated if recurrent infection occurs; there is currently no good evidence regarding the optimum duration of suppressive treatment.
Treatment with cetirizine (10mg od) for six months may cause remission in women who fail to get resolution of symptoms with suppressive fluconazole.1
Some women take antifungal treatment whenever they take antibiotics to prevent thrush from occurring. There is little scientific evidence to show that natural remedies are effective.
Neither suppositories nor yogurt containing Lactobacillus spp are likely to prevent recurrences of VVC so their use is not recommended. 6
C. glabrata does not form pseudohyphae or hyphae and is not easily recognised on microscopy. C. glabrata and other non-albicans candida species are seen in around 10-20 per cent of patients with RVVC and are usually still sensitive to standard treatment.
Patients with abnormal host factors
Women with diabetes mellitus should ensure they achieve optimal glycaemic control. Patients with immunosuppression may have more frequent and more persistent episodes of candidiasis. 7
Women who are taking the combined oral contraceptive pill should be advised to consider changing to a progesterone-only contraceptive.
If infection occurs during a maintenance period of treatment, then the patient should be referred to a GUM clinic, as alternative treatments, including boric acid, may be required. 8 Boric acid is a weak acid with both antiseptic and anti-fungal properties.
OUTCOME OF CLINICAL CASE
Mrs R G was examined and swabs were taken, which conﬁrmed the presence of Candidia albicans . All other tests for sexually transmitted infections were negative, for which she was very relieved. She was prescribed oral ﬂuconazole to take that day and again three days later. She was also given clotrimazole with hydrocortisone (Canesten HC) cream to use topically.
Mrs R G’s GP discussed with her practical preventive measures and also explained that she may need to consider changing her choice of contraception if her symptoms recurred. Mrs R G returned to the surgery three months later saying she was delighted that her symptoms had not returned.
1 RCGP Sex, Drugs, HIV and Viral Hepatitis Group, BASHH. Sexually transmitted infections in primary care 2013. http:// www.bashh.org/documents/Sexually%20Transmitted%20 Infections%20in%20Primary%20Care%202013.pdf
2 Clinical Effectiveness Group. British Association of Sexual Health and HIV. United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis (2007)
3 Faculty of Sexual and Reproductive Healthcare. The management of vaginal discharge in non genito-urinary medicine settings (2012). Available at www.fsrh.org and www. bashh.org/guidelines
4 British National Formulary (BNF)
5 Bradbury BD, Jick SS. Pharmacotherapy 2002 Jun;22(6): 697-700.
6 Jurden L, Buchanan M, Kelsberg G, Safranek S. J Fam Pract 2012 Jun;61(6):357, 368
7 Ray A, Ray S, George AT, Swaminathan N. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD008739. doi: 10.1002/14651858.CD008739.pub2.
8 Savini V, Catavitello C, Bianco A, et al. Eur J Obstet Gynecol Reprod Biol 2009 Nov;147(1):112.