Yeast Infections

Overview: Recurrent Yeast Infections

• Approximately 55% to 75% of all women experience vulvovaginal candidiasis (VVC) during their lifetime, and up to 40% to 50% of them will have recurrent episodes.

• Approximately 8% of women will have recurrent vulvovaginal candidiasis (RVVC), as defined by four or more episodes in a year.

• By age 25 years, half of all college women will have experienced at least one physician-diagnosed case of VVC.

• VVC is extremely rare in premenstrual years and increases in reproductive age. It also tends to be less frequent in postmenopausal women, although women who are undergoing estrogen therapy generally have higher frequency of VVC.

• VVC is a spectrum of conditions with variable number of organisms and a variable degree of symptoms. Most highly symptomatic women have a large number of organisms with florid exudative vaginitis or thrush, most likely resulting from a combination of reduced local protective cellular responses and increased immediate hypersensitivity reaction.

• Other women have minimal symptoms with large numbers of organisms, most likely secondary to reduced local protective immune responses.

• Still other women are highly symptomatic with a small number of organisms and without thrush, most likely because of an immediate hypersensitivity response.

• Candida albicans, the most common pathogen implicated in RVVC, causes approximately 90% of cases.

• Other species include Candida glabrata (second most common), Candida parapsilosis, Candida krusei, Candida tropicalis, Candida lusitaniae, Saccharomyces cerevisiae, and Trichosporon spe- cies.

• However, approximately 20% to 25% of asymptomatic women are colonized by Candida in their vagina, as shown by culture.

• Candida also seems to be part of the normal vaginal flora and is in equilibrium with other bacterial and vaginal defense mechanisms.

  
  

Important Points to Consider

• Receiving orogenital sex and using any form of contraceptive, having a high body mass index, having impaired glucose tolerance, consuming excessive sweets, and having high stress levels constitute some of the risk factors for recurrent vulvovaginal candidiasis.

• Yogurt or probiotics that contain multiple species of Lactobacillus may inhibit the growth of Candida species.

  • Oral or topical use of one or two Lactobacillus species may not be helpful in preventing recurrent vulvovaginal candidiasis because these species may not have specific action against the organism causing the infection

• Recurrent infections that do not respond to standard therapies may be caused by more than one species of Candida, and some of these species may be resistant to imidazoles and triazoles. Some patients may need long-term maintenance therapy, and some may require combination regimens.

• Reducing risk factors for vulvovaginitis may prevent recurrence.

Prevention Prescription

• Avoid receiving oral sex for recurrent infections.

• Practice unhurried intercourse with extra lubrication to avoid trauma to the vaginal mucosa.

• Avoid using saliva for masturbation.

• Wear well-ventilated clothing.

• Consider discontinuing oral contraceptives with high doses of estrogen.

• Avoid douching.

• Avoid eating simple carbohydrates and sweets.

• Achieve optimal glycemic control in diabetes.

• Follow a diet and exercise program (useful with high body mass index and impaired glucose tolerance for prevention).

• Stop smoking.

• Treat depression, with effective stress management in recurrent cases.

• Ensure daily ingestion of yogurt containing multiple strains of Lactobacillus.

• Ensure a daily intake of garlic.

Therapeutic Review

Recurrent vulvovaginal candidiasis (RVVC) is often difficult to cure and may require an integrative approach along with conventional therapy. Some of the integrative approaches include nutrition and supplements, mind-body work, and risk factor reduction, along with longer-term pharmacotherapy.

Mind-Body Therapy

• Deep breathing, relaxation, yoga, and meditation may be useful in highly stressed individuals to prevent recurrences by enhancing immune function.

Nutrition and Supplements

• Ingestion of 8 oz of yogurt containing multiple active species of Lactobacillus on a daily basis (Look for the “Live Active Culture” seal on the label, which requires 10^8 viable lactic acid bacteria per gram.)

• Use of probiotics containing multiple active species of Lactobacillus (10^9 organisms) on a daily basis.

Botanicals

• Tea tree oil (5% to 10%) may be used topically in patients who are not allergic to it.

  • Fresh garlic cloves nightly intravaginally or 500 mg of garlic extract may be used orally two to three times daily.

Pharmaceuticals

• For uncomplicated VVC:

  • Fluconazole: 150 mg orally once.

  • Clotrimazole vaginal (Gyne-Lotrimin): 200-mg suppository or 2% cream nightly for 3 days.

• For potentially resistant Candida strains, consider:

  • Terconazole vaginal (Terazol): 80-mg suppository or 0.8% cream nightly for 3 to 7 days.

• For complicated VVC:

  • Oral fluconazole: 150 mg every 72 hours for 9 to 14 days.

  • Oral ketoconazole: 200 mg once or twice daily orally for 14 days.

  • Boric acid: 600 mg intravaginally daily for 14 days.

• For RVVC and resistant VVC:

  • Maintenance therapy with fluconazole: 100 or 150 mg once a week long term.

  • Combination therapy with topical boric acid, nystatin or flucytosine (17%), and oral itraconazole: may be needed for some patients with recurrent and resistant cases.

Key Web Sources

• womenshealth.gov

• http://www.womenshealth.gov/faq/vaginal-yeast-infections.cfm

• http://www.floracopeia.com

• http://www.mountainroseherbs.com/ aroma/ess.html