What is Vaginal Candidiasis?
Vulvovaginitis is an inflammation of the outer and inner parts of a woman’s sexual organs, specifically the vulva and vagina. This condition often affects women who are in their reproductive years and can be due to various causes. A common cause of vulvovaginitis is a fungal infection by a fungus called Candida albicans. This fungus is versatile and can cause infection when the conditions are favorable. When vulvovaginitis is due to this fungus, it’s often referred to as vaginal candidiasis. About one in three cases of vulvovaginitis is due to this fungal infection.
Typical signs of this condition include redness and small skin surface scrapes in the vulva and vagina, thick white sticky discharge, and swelling. The way to diagnose this condition mainly involves physical examination by the doctor and various lab tests. These tests include a check of the vaginal fluid under a microscope, testing the acidity (pH level) of the vagina, and taking samples to check for other types of infections that could cause a different discharge and infection, like bacterial vaginosis, and infections caused by gonorrhea and chlamydia bacteria.
The objective for healthcare professionals in managing vaginal candidiasis is to enhance their ability to detect this condition early, carry out effective treatments, and improve coordination of care. This is all aimed at leading to better health outcomes for their patients.
What Causes Vaginal Candidiasis?
Candidal vulvovaginitis, more commonly known as a yeast infection, is caused by changes in the tissue lining of the vagina and vulva due to an infection from Candida species, most commonly Candida albicans. To clarify, it’s important to know that Candida is normally found in many women, with up to 10% of healthy women having it without showing any symptoms at all.
So for a yeast infection, or candidal vulvovaginitis, to occur, Candida needs to be present in the vagina but it also needs to cause symptoms. These symptoms could be things like irritation, itching, a burning sensation when urinating, or inflammation.
Risk Factors and Frequency for Vaginal Candidiasis
Candidal vulvovaginitis, also known as yeast infection, is a common issue that accounts for a third of all vulvovaginitis cases in women of reproductive age. It’s estimated that around 70% of women will experience this condition at some point in their lives, and 8% of women might have recurring episodes. The main cause is a yeast called C. albicans, responsible for 90% of cases, followed by Candida glabrata, which causes most of the remaining cases.
Since many women use over-the-counter treatments, the actual number of yeast infection cases is likely higher than reported. Also, diagnosing is complicated as it involves both clinical examination and additional tests. This means that studies relying only on culture tests, which show positive results in 10% of women without symptoms, might overestimate how widespread this condition is. Furthermore, studies have shown that self-diagnosis can often be inaccurate, so data based on patient self-reports might not be completely reliable.
- Risk factors for getting a yeast infection include using estrogen, having high levels of estrogen naturally (like during pregnancy or obesity), having diabetes, having a weak immune system (due to conditions like HIV or treatments like chemotherapy), and using broad-spectrum antibiotics.
- Although yeast infections are more common in sexually active women, there is no proven connection between these infections and sexual transmission.
- Women who have recurrent yeast infections, defined as four or more instances of a confirmed yeast infection, may have specific genetic factors making them more prone to these infections.
- These genetic factors may also make these women more likely to have hypersensitivity reactions to Candida yeast.
Signs and Symptoms of Vaginal Candidiasis
Vaginal candidiasis creates uncomfortable symptoms such as irritation, itching, and burning in the vaginal and vulvar regions. These symptoms often become more noticeable immediately before a woman’s menstrual cycle. Some women may have experienced recurring bouts of these symptoms and tried over-the-counter creams or alternative treatments.
During a pelvic exam, medical professionals may notice certain signs of this condition. These can include
- Redness (erythema) in the vulva and vagina
- Scratches or abrasions due to itching (excoriations)
- A thick, white, sticky discharge
- Swelling
However, some women might not have any noticeable discharge. Signs of inflammation in the outer vagina (vulva) and inside the vagina can be seen. It’s important to note that the cervix (the lower part of the uterus that connects to the vagina) usually looks normal and not inflamed. Pain when the cervix is moved, or any abnormal discharge from the cervix, shouldn’t be present. If professionals find ulcers, lumps or swelling that’s not symmetrical, a foreign body, or consider other possible diagnoses.
Discomfort can be severe for women with an acute form of this condition, called vulvovaginal candidiasis. On the other hand, people with infections due to a type of yeast called Candida glabrata may have mild symptoms. Because various causes of vulvovaginitis (inflammation of the vulva and vagina) can have similar symptoms, further tests like wet mount, whiff test, and pH testing might be necessary if it’s not clear what’s causing the symptoms.
Testing for Vaginal Candidiasis
To confirm the presence of Candida, the fungus causing yeast infections, doctors use various tests. These include a microscope exam of a slide covered in the vaginal discharge mixed with a solution called 10% potassium hydroxide (KOH), pH testing, and possibly a fungal culture or PCR tests. The PCR test is a lab method commonly used to create many copies of a specific part of a DNA strand (the genetic material). People with vaginal yeast infections generally have a vaginal pH of less than 5.
Important signs of a yeast infection include a high number of lactobacillus bacteria and inflammatory cells (cells that are part of the body’s response to injury or infection) visible in the wet prep (the slide with the discharge and wet KOH). There’s also a negative Whiff test, meaning no fishy smell is found when KOH is added to the slide. In addition, budding yeast, hyphae (branching filaments of fungi), or pseudohyphae (structures appearing similar to true hyphae) can be seen under a microscope. This is usually clear on the KOH prep slide.
Microscopy and pH testing can also discover clue cells (which suggest bacterial vaginosis, an infection due to an imbalance of bacteria in the vagina) or trichomonads (parasites that cause a sexually transmitted infection called trichomoniasis). These can be ruled out or diagnosed at the same time.
The majority of yeast infections are due to Candida albicans. Microscopy findings in reproductive-age women with vulvovaginitis symptoms (inflammation or infection of the vulva and vagina) should promptly confirm the infection. So, if Candida is suspected, cultures are not necessary. However, cultures should be considered for patients with recurring symptoms or if work-ups are negative despite symptoms pointing to a yeast infection.
If cultures are not possible, empirical treatment (treatment based on previous successful results) is another reasonable approach. Candida is part of the normal vaginal microflora in many women; thus, routine cultures aren’t recommended if there are no symptoms of infection.
Treatment Options for Vaginal Candidiasis
Acute candidal vulvovaginitis, a yeast infection in women, is often treated with antifungal medications. Most of these infections are caused by a fungus called Candida albicans. Since this type of fungus doesn’t show resistance to a group of antifungal medicines known as azoles, these are the chosen treatment.
These antifungal medicines can be given in various ways, such as a one-time oral dose of a medicine called fluconazole, or an antifungal cream like terconazole applied directly to the vagina. These treatments can also vary in length, ranging from a single dose to a regimen over 3 to 7 days, which can be bought without a prescription. These treatment options are equally effective in patients with a simple yeast infection, meaning those who have a healthy immune system and don’t frequently get these infections. Therefore, deciding on a treatment can be based on factors like cost, personal preference, and potential interactions with other drugs.
If a patient doesn’t respond to these treatments, it might be necessary to perform laboratory tests to check for strains of Candida that are resistant to the standard treatment.
For complex cases of candidal vulvovaginitis, such as in patients who have a weakened immune system or recurrent infections, longer treatment plans are commonly used. These include using an azole cream inserted into the vagina for at least a week or taking oral fluconazole every 3 days for 3 doses. Patients who frequently get yeast infections may benefit from preventative treatment with weekly doses of oral fluconazole for 6 months. However, pregnant women shouldn’t be given oral antifungals. For these patients, a 7-day course of cream applied directly to the vagina is suggested. Fluconazole is considered safe in breastfeeding women.
The use of home remedies such as yogurt or garlic, applied orally or intravaginally, or douching, have not proven to be effective.
What else can Vaginal Candidiasis be?
When a doctor is coming up with a diagnosis, they also need take into consideration other conditions that may have similar symptoms. These could include:
- Allergic reaction
- Atopic dermatitis (a type of eczema)
- Lichen sclerosis (a skin condition)
- Lichen simplex chronicus (a skin disorder leading to chronic itching)
- Neoplasm (an abnormal growth of tissue which may be cancerous or benign)
- Paget’s disease (a condition that interferes with your body’s normal bone recycling process)
- Physiologic leukorrhea (a normal vaginal discharge)
- Psoriasis (a skin disease that causes red, itchy skin patches)
- Sexual abuse
- Vulvodynia (chronic vulvar pain without an identifiable cause)
What to expect with Vaginal Candidiasis
Despite the right treatment, there’s a chance that the infection can return. It is thought to happen in 14% to 28% of healthy people. Usually, the infection comes back because the organisms that cause the infection are still present in the vagina, or because a person has been infected again with the same type of fungus, called Candida. Occasionally, a person might get the infection from a different type of Candida. The return of the infection could be because of things like taking antibiotics, sexual activity, or certain foods in the person’s diet. Some people might also be more likely to get the infection again because of their genes.
Certain medications like topical imidazole and oral fluconazole might not work as well in people with a Candida species other than albicans. So, if a person’s symptoms persist even after they have been given the standard treatment for straightforward vulvovaginal candidiasis (a common yeast infection of the vagina), a fungal culture may be taken. This means a sample of the fungus is collected and grown in a lab for further study. Boric acid can also be effective against C. glabrata and other atypical species. This is usually administered vaginally at a 600mg dose for at least 14 days. It’s important to know that boric acid can be dangerous if swallowed, so patients must be careful when using it and follow their doctor’s advice.
Possible Complications When Diagnosed with Vaginal Candidiasis
While complications from vaginal yeast infections are unusual, in more serious cases, it can lead to significant redness, swelling, open sores, and cracks in the skin in the genital area. Side effects that might come up with treatment for the yeast infection include a number of symptoms like:
- Stomach pain
- Nausea and vomiting
- Diarrhea
- Gas
- Headache
- Brain and spine disorders
- Bone and muscle disorders
- Skin rash
- Allergic reaction
- Irregular periods
- Hair loss
Preventing Vaginal Candidiasis
Patients should only use recommended treatments for vaginal yeast infections. Using over-the-counter medication without a doctor’s advice could delay treatment and may even lead to other types of vaginal infections. Doctors don’t usually recommend using probiotics or home remedies for treating vaginal yeast infections because there’s little scientific evidence showing that these work.
If your symptoms continue, your doctor will ask you to come back for additional visits to keep track of your condition. To help prevent future yeast infections, there are some general tips. Try to keep the vaginal area dry, especially after swimming or working out – change out of your wet clothes promptly. Try not to use soap on this part of your body and opt for clothing made from breathable fabrics.
Douching, or washing or cleaning out the vagina with water or other mixtures of fluids, is not recommended as it could disrupt the natural balance of organisms. Keep in mind that if you’re taking antibiotics, you might want to consider preventative yeast infection treatment, as antibiotics can sometimes increase the risk of developing this infection.
