INTRODUCTION — Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections because they are frequently diagnosed without an examination. In addition, many women treat themselves with over-the-counter yeast treatments before seeking medical advice.
Yeast infections occur mainly in women who are menstruating (having monthly periods). They are less common in postmenopausal women who do not take estrogen and in girls who have not yet started menstruating.
Vaginal yeast infections are also called yeast vaginitis or vaginal candidiasis.
SYMPTOMS — Itching of the vulva is the most common symptom of a vaginal yeast infection (show figure 1). Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge. If present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases.
Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. (See "Self-diagnosis" below).
CAUSE — Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina). Normally, Candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, Candida may multiply and cause the characteristic symptoms, described above.
Candida albicans causes 80 to 92 percent of episodes of vulvovaginal candidiasis. Some investigators have reported an increasing frequency of other candida species, particularly C. glabrata, possibly due to widespread use of over-the-counter drugs, long-term use of suppressive yeast infection treatments, and the use of short courses of antifungal drugs.
RISK FACTORS — In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including: Antibiotics — Most antibiotics kill a wide variety of bacteria, including those that normally live in the vagina. These bacteria function to protect the vagina from the overgrowth of yeast. Some women are prone to yeast infections while taking antibiotics. Hormonal contraceptives (eg, birth control pills, patch, and vaginal ring) — The risk of yeast infections may be higher in women who use contraceptives containing estrogen. Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine devices (IUDs) have been associated with a higher risk of yeast infection. Spermicides have not, although spermicides frequently cause vaginal irritation. (See "Patient information: Contraception"). Immunosuppression — Yeast infections are more common in patients who are immunosuppressed due to infection with HIV or use of immune-suppressing medications (steroids, chemotherapy, post-organ transplant medications). Pregnancy — Signs and symptoms of a yeast infection are more common during pregnancy, although there are little data to know if yeast infection is always the cause. Diabetes — Women with diabetes are at higher risk for yeast infection, especially when blood glucose levels are frequently higher than normal.
Vaginal yeast infections are not considered to be a sexually transmitted infection. They can occur in women who have never been sexually active but are more common in women who are sexually active. Yeast infections are no more frequent in women who have sex frequently, but may develop more frequently in women who receive oral sex.
DIAGNOSIS — Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used; the diagnosis is harder to make if symptoms have resolved or if treatment was started before an examination and diagnostic testing. The combination of a medical history, physical examination, and diagnostic testing correctly diagnoses vaginal yeast infection in about 60 percent of women.
Diagnostic testing may include measurement of the vaginal pH; normally, the pH of vaginal discharge is acidic. Examination of the vaginal discharge under a microscope (called a wet mount) allows the provider to look for yeast buds and hyphae, which resemble branches of a tree (show picture 1). Other infections can be diagnosed with wet mount, including bacterial vaginosis and trichomoniasis.
Further testing with a yeast culture may be needed for a woman who has symptoms of a yeast infection but no evidence of yeast on wet mount. Culture is also useful in women with recurrent or persistent signs and symptoms who have a negative wet mount or do not respond to treatment. Yeast culture and sensitivity can determine if nonalbicans yeast is present and can guide treatment in these cases.
Self-diagnosis — Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. In one study, only 11 percent of women accurately diagnosed their infection; women with a previous yeast infection were only slightly more accurate (35 percent correct) [1].
Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina.
TREATMENT — Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary according to the formulation; one, three, and seven-day treatments are equally effective.
Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose, although women with more complicated infections (such as those with underlying medical problems, recurrent yeast infections, or severe signs and symptoms) may require a second dose 72 hours (3 days) after the first dose. Side effects of fluconazole are mild and infrequent, but may include stomach upset, headache, and rash. Fluconazole interacts with a number of medications; a healthcare provider or pharmacist should be consulted if there are concerns about drug interactions. Fluconazole should not be taken during pregnancy.
Uncomplicated yeast infections usually resolve within a few days of treatment. Complicated infections may require more time to completely resolve; the infection generally resolves within a few days but the vulvar and vaginal irritation can persist for up to 2 weeks.
Women who do not improve after treatment with a standard oral or vaginal treatment for yeast infection should be reexamined. A different species of yeast, known as Candida glabrata, is less likely to respond to standard treatments, and can usually be diagnosed with a vaginal yeast culture.
RECURRENT YEAST INFECTIONS — Between 5 and 8 percent of women have recurrent yeast infections, defined as more than four infections per year. Risk factors for recurrent infection include the use of panty liners, pantyhose, or sexual lubricants, or the consumption of cranberry juice. Avoidance of these products may reduce the frequency of infection in some women.
There is no evidence that eating yogurt or other products containing live Lactobacillus acidophilus, or applying these products to the vagina is of any benefit in women with recurrent vaginal yeast infections.
Diagnosis — As with initial yeast infections, it is important to correctly diagnose recurrent yeast infections. A woman who has frequent signs and symptoms of vulvar or vaginal irritation or itching should be seen by a healthcare provider to ensure that her symptoms are from yeast, not as a result of other common problems (eg, other vaginal infections, allergic reaction or sensitivity to products such as detergents or soaps). As with initial infections, self-diagnosis is not accurate enough to recommend treatment.
Treatment — Women with recurrent infections should use a longer course of treatment for infections, between 10 to 14 days for a topical (cream or suppository) medication or fluconazole 150 mg by mouth with a second dose 72 hours later.
Preventive treatment can be started after the infection has resolved; this may include fluconazole (150 mg orally once per week) or clotrimazole (500 mg vaginal suppositories administered once per week).
Treatment of a sexual partner — Vaginal yeast infections are not considered to be a sexually transmitted infection, though the infection can rarely be passed from one partner to another. Most experts do not currently recommend treatment of a sexual partner.
SUMMARY Vaginal yeast infections are a very common problem in women. It is difficult to know the true percentage of women affected by yeast infections; they are frequently diagnosed without an examination and many women treat themselves with over-the-counter yeast treatments before seeking medical advice. Itching of the vulva is the most common symptom of a vaginal yeast infection. Women may also note pain with urination, vulvar soreness or irritation, pain with intercourse, or reddened and swollen vulvar and vaginal tissues. There is often little or no vaginal discharge; if present, discharge is typically white and clumpy (curd-like), but may be thin and watery in some cases. Symptoms of a yeast infection are similar to a number of other conditions, including bacterial vaginosis (a bacterial infection of the vagina), trichomoniasis (a sexually transmitted infection), and contact or allergic dermatitis (a skin reaction to an irritating or allergic substance) (show table 1). It is often not possible to know, based on symptoms alone, if vulvar itching is caused by yeast or other potential causes. Candida albicans is a fungus that normally lives on the skin and mucous membranes (mouth, nose, vagina); it causes most cases of vaginal yeast infections. Normally, candida causes no symptoms. However, when the skin or mucous membranes undergo changes due to medications, injury, or stress to the immune system, candida multiplies and causes the characteristic symptoms of a yeast infection, described above. In most women, there is no underlying disease or event that leads to a yeast infection. There are several risk factors that may increase the chances of developing an infection, including use of antibiotics, hormonal contraceptives and certain contraceptive devices, diabetes, pregnancy, and a weakened immune system (due to chemotherapy, HIV, or certain medications). Diagnosis of a vaginal yeast infection requires that a healthcare provider take a medical history, perform a physical examination, and perform diagnostic testing. It is important to visit the provider when symptoms are present and before any treatment is used. Women with symptoms of vulvar itching or vaginal discharge frequently assume that their symptoms are related to a yeast infection and treat themselves with an over-the-counter treatment. Incorrect self-diagnosis and treatment can delay receiving the correct diagnosis and treatment and wastes money on improper treatment, which frequently causes further irritation of the vulva and vagina. Treatment of vaginal yeast infection may include a topical cream or tablet; most are applied inside the vagina at bedtime with an applicator. Treatment durations vary; one, three, and seven- day treatments are equally effective. Oral treatment is available as fluconazole (Diflucan®) 150 mg. Most patients require only one dose
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
U.S. Department of Health and Human Services
(www.4woman.gov)
[1-3]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Ferris, DG, Nyirjesy, P, Sobel, JD, et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis(1). Obstet Gynecol 2002; 99:419.
2. National guideline for the management of vulvovaginal candidiasis. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S19.
3. Rex, JH, Walsh, TJ, Sobel, JD, et al. Practice guidelines for treatment of candidiasis. Clin Infect Dis 2000; 30:662.
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