Roughly 75% of reproductive aged females will experience at least one vaginal yeast infection (vulvovaginal candidiasis or VVC), with half of them developing a second episode at some point.  Additionally, between 5-9% of these women will go on to develop recurrent vulvovaginal candidiasis, meaning numerous episodes over the course of a year.

Vulvovaginal candidiasis is clearly noted as one of the most common vaginal infections experienced by women of childbearing age with symptoms that are very familiar to many of us. Symptoms of VVC often include vaginal and vulvar itching, burning, irritation, pain with intercourse, and a thick, white discharge. Unfortunately, symptoms of VVC often overlap with other vulvovaginal conditions and thus are often assumed to be VVC when in fact they are a constellation of symptoms attributable to another condition. Furthermore, it is not uncommon for individuals to have more than one microbe responsible for the upset within her vaginal ecosystem. For these reasons it is important for women experiencing vaginal symptoms to be evaluated by a provider so that objective testing may be used to decipher the precise cause of imbalance. Such testing may include vaginal pH evaluation, microscopy, culture, or testing for fungal DNA.

There are numerous factors that play a role in the development of recurrent VVC. For example, an increased estrogenic state such as that seen in pregnancy or achieved with use of oral contraceptive pills may increase the risk of a patient developing VVC. The use of antibiotic medications should be considered as a potential risk factor for a woman developing VVC as it likely alters the vaginal microbiota. While I am in no way advocating against the above listed medications, I am encouraging a heightened awareness of VVC in persons with these conditions or using these medications. Additionally, persons with compromised immune systems are often at heightened risk for the development of recurrent VVC. Although most women with VVC do not have the following conditions, individuals who have been diagnosed with diabetes, human immunodeficiency virus (HIV), or who routinely take glucocorticoids or immune suppressing agents may experience recurrent episodes of VVC

Conventional treatment of VVC generally includes an anti-fungal agent, often one that falls into the azole class of medications, such as oral fluconazole or topical miconazole. Although there are numerous additional options within the azole class, additional classes of antifungal medications are few.  These limited treatment options have presented a challenge, as there are increasing numbers of cases of azole resistant candida.

Candida albicans is the predominant culprit with VVC, however, several other species of yeast may contribute to symptoms. Knowledge of the distinct species may be helpful in selection of treatment as not all species of candida are susceptible to the same methods of treatment. For example, Candida glabrata is generally not impacted by the use of azole medications but will often respond favorably to a course of vaginal boric acid.  Evidence suggests that the use of boric acid 600 mg used intravaginally daily for two weeks may be helpful in the resolution of VVC in cases where non-C. albicans strains have been detected. One study in women with diabetes indicated greater VVC cure rate of C. glabrata with use of vaginal boric acid 600mg for 14 days (63% cure rate) than a single-dose of oral fluconazole 150 mg (28% cure rate). These findings further advocate for knowledge of specific strains prior to treatment.

There are various boric acid regimens depending on the severity of the infection, recurrence, and an individual’s health history. And while it may be enticing to attempt treatment with boric on one’s own, it is best to seek care from your women’s health provider. It should be noted that it is possible that boric acid used vaginally may result in temporary irritation to vulvovaginal tissue. In such instances, a topical barrier salve or ointment may be used to protect the tissue. With regards to safety, boric acid should be avoided during pregnancy and it must not be consumed orally, as it can be fatal.

 

The take away:

  • Vulvovaginal yeast infections are common but so are other vaginal infections.
  • It is important to see your women’s health provider for appropriate evaluation of vaginal discharge or vulvovaginal irritation.
  • There are numerous methods by which VVC may be treated but specific treatment protocols are dependent upon the type of infectious agent as well as a person’s health history.