Yeast Infections and what to do about them

By Sara Twogood, MD

Candida (commonly known as “yeast”) can be a part of the normal flora of the vagina. It’s maintained at a normal level by the helpful acidic environment of the vagina and those wonderful lactobacilli that keep the vaginal pH in check. But sometimes it grows just too much. And that growth causes some excruciatingly uncomfortable symptoms called a yeast infection. Medical professional call it vulvovaginal candidiasis. Know these are the same! There are many types of Candida but the one responsible for most yeast infections is Candida albicans.

And since more than 75% of women (and people with vaginas) will have a yeast infection at some point in their life, it’s important to know about them. 

Have no fear – I’ll run you through the symptoms, the treatments, and ways to prevent them in the first place

How can you tell if you have a yeast infection? 

Symptoms:

• Thick, white discharge –aptly described as “cottage cheese”. Gross but true. This discharge sticks to the vaginal walls and is very obvious on pelvic exam. Sometimes there is a yellow or pink tint as well

• Itching. So much itching. Scratching doesn’t make it better

• Inflammation

• Swelling with red / hot / angry skin – this is called erythema

• Burning

• Little tears / fissures

• Increase in discharge in vaginal discharge in general, even if it’s those thick white clumps

If you aren’t sure it’s a yeast infection, I encourage you to have an evaluation by your health care practitioner. Yeast infections can be easily confused with other infections like BV or STIs. They’re all treated differently, so treating yourself for a yeast infection when it’s not a yeast infection won’t do anything and may even exacerbate your symptoms!

One other warning: if vaginal swabs or pap smears are done for some other reason, up to 20% of people will be positive. A positive test without symptoms is meaningless because it could be normal flora of the vagina. It is not recommended to treat based on a lab test alone. Treatment is to help with symptoms!

Ok. You’ve self-diagnosed and you’re certain it’s a yeast infection. What are your treatment options? 

These are separate into 2 big categories: topical (vaginal creams / suppositories) and oral (pills).

In most studies, patients prefer the pills. But there are pros and cons to both!

Here’s the run down

Topical / local treatment: 

OTC miconazole (Monistat). This medication is inserted into the vagina to get rid of the yeast overgrowth. 

Tips: 

• USE THE 7 DAY COURSE. I know it’s tempting to just use the 1 or 3-day course but guess what? They all get rid of the yeast symptoms in the same amount of time! The 1 and 3-day doses are so concentrated that they cause inflammation of the skin – that can temporarily worsen symptoms. Plenty of people have treated themselves and 2-3 days later call, worried, that their symptoms are better and is maybe even worse. That’s the skin irritation!

• Vulvar treatment is not enough. The medication needs to be intravaginal to treat completely 

Good: can self-treat, don’t need prescription. Can be used in pregnancy. 

Bad: skin irritation can occur. And sometimes it’s just annoying to use vaginal suppositories for a week. 

Other topicals are available but less commonly used. These are prescription too, so your doctor would be discussing why these could / should be used instead of OTC miconazole

These include clotrimazole, terconazole, nystatin, boric acid, flucytosine cream, amphotericin, and gentian violet

Oral treatment: 

Diflcuan (fluconazole): a one-time pill that works by stopping growth of yeast cells. It’s a one pill, one dose prescription and should work within 72 hours. For severe symptoms, it’s reasonable to repeat the dose in 72 hours (the prescriber will let you know!)

Brexafemme is the new kid on the block.  One day treatment – 2 pills in AM and 2pills in PM. It works by killing yeast, not just stopping their growth. It’s anticipated that Brexafemme will be used only when fluconazole can’t be – so we’re probably not going to be seeing a lot of this medication anytime soon.

For both:

Good: Less time than the topical treatment and same efficacy. Can forgo the mess. Good for people who feel uncomfortable putting things inside the vagina or if 2 simultaneous vaginal infections are present at the same time. I had a patient with the unfortunate combo of a yeast and herpes outbreak. Topical yeast treatment would have been too painful for the herpes lesions, so we opted for oral fluconazole instead 

Bad: Not a lot as they are usually well tolerated. Fluconazole is cheap, but Brexafemme will be expensive.  A bit of nausea is common. They are processed through the liver, so with chronic or frequent treatment, liver abnormalities can occur. Not allowed to drink alcohol while taking them! And, you’ll need a prescription. It is totally reasonable to ask for a Rx at your annual exam to have on hand just in case. I do this all the time! And most offices will prescribe without an exam or office visit, but it might take a day or so to get the prescription in, especially if it’s a weekend

Others oral medications that are rarely used: itraconazole and ketoconazole. I’ve never prescribed either one! 

Some helpful tips: 

It can be perfectly safe to treat yourself without needing evaluation by your doctor. I, in fact, do not need or even particularly want to know if a patient had a yeast infection and treated herself … as long as it went away!

If you’re unsure about your symptoms, be evaluated before self-treating– it may not be yeast after all! Using miconazole or fluconazole for a non- yeast infection won’t get rid of it and may actually cause more symptoms. 

If your symptoms do not go away within the 7 days after starting treatment, be evaluated. It may be something besides yeast. And there are uncommon types of yeast that are resistant to the traditional treatments (all Candida but NOT Candida albicans: Candida glabrata; Candida tropicalis, Candida parapsilosis; Candida krusei)

What about recurrent yeast infections?

A small percent of the population will have recurrent yeast infections – this is defined as more than 4 infections in a year.

We typically want the infections to be documented as yeast (through vaginal swabs) to make sure it actually is a yeast infection that is causing the symptoms. 

Options for treatment: 

• Chronic fluconazole – 1 pill every 3 days for 3 doses, then weekly for 6 months. This solves the problem in about 50% of the population. The rest? Well, unfortunately the infections return once the fluconazole is stopped

• Just treat every infection as it pops up

• Or treat every infection for longer (Diflucan 2-3 doses or 7-12 days of topical) 

• There is some information that yeast responsible for recurrent yeast infections originates in the intestines (GI tract).  Remember how close the vagina and anus are? Close enough to contaminate one another with yeast!  If we’re trying to help with this hypothetical cause, oral nystatin, probiotics, and an anti-candida diet may help

Preventing yeast infections! Here’s what we really want to do – prevent them from happening in the first place! 

There are lots of options here. Some traditional that you may have heard of, others not so traditional: 

• Yeast thrives in moist environments. Keep the area as dry as possible. Don’t linger in a wet swimsuit or sweaty gym clothes.

• Let the area breathe: Wear cotton underwear and consider going commando at night. Polyesters and silk fabrics keep moisture trapped in the area. Avoid panty hose. Spanx or other girdle devices too. 

• Avoid panty liners

• During a period, change pads and tampons frequently. If using menstrual cup or disc, make sure it is sterilized (not just clean). 

• Use antibiotics sparingly and only at direction of a doctor with a specific diagnosis / explanation.  Systemic antibiotics (taken in pill form) don’t discriminate. They kill the bad bacteria causing an infection but can also disrupt good bacteria too. That disruption can shift the balance of bacteria in the vagina. If you are particularly sensitive to this, reasonable to take a Diflucan with antibiotics to prevent this shift. 

• Use prebiotics / probiotics  – no strong evidence that they help maintain a healthy vaginal pH, but I like them for intestinal issues and they may be helpful, so go for it!

• Keep sugar low, especially if you’re a pre-diabetic or a diabetic or pre-DM 

• Try an anti-candida diet. This usually includes low sugar and low alcohol. No refined sugars or desserts. No fruit juice, honey, sweet foods. No dairy except yogurt. Avoid citrus fruits and sour food products. Eat food high in fiber and oat bran.

• Avoid douching – this disrupts the vaginal pH even more!

• Stop putting stuff on the vulva or in vagina altogether. People use all sorts of products on their vulva for all sorts of reasons (and believe me, I’ve heard a lot of them!). Essential oils, powders, creams, soaps, deodorants? Avoid them! The chemical can disrupt vaginal pH and cause skin inflammation or irritation.

• Change your contraception – if using hormonal contraception, consider changing to something non-hormonal. If IUD is in place, consider removing it or exchanging it (the strings may be colonized with yeast, making it easier to get a yeast infection). If diaphragm, sterilize. 

• Decrease stress and get some sleep. Because this can help with just about everything.