Genital infections




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Thrush in women

Thrush is caused by the yeast Candida albicans. About 2 women in 5 has Candida in her vagina, without it causing any symptoms. Hormones in the vaginal secretions and the friendly vaginal bacteria keep it at bay. Problems arise when this natural balance is upset, and Candida multiplies. This can happen:

during pregnancy (but thrush is less likely during breastfeeding)
when you take antibiotics (because these get rid of the friendly bacteria)
if you have diabetes, especially if your blood sugar levels are consistently too high
if you wear tight, non-porous underwear, such as nylon knickers and tights (because Candida thrives in warm, moist conditions)
if the vulva or vagina is sore for any other reason, particularly if you scratch (because damaged tissue is more susceptible to Candida)
if you are ill for any reason
if you are taking any drugs, such as steroids, which lower the body’s resistance to infection.

Attacks of thrush are very common. Most women have had at least one attack by their mid-20s. Thrush is not a dangerous infection, but it can cause a lot of distress if it keeps coming back. It is very uncomfortable and can wreck your sex life.

Myths about thrush – true or false?

The contraceptive pill causes thrush
Probably false. Doctors are still arguing about this, but there is very little evidence for it

Thrush is a sexually transmitted disease
False. Women who are not sexually active can suffer from thrush. The Candida yeasts are already in the vagina, and they cause thrush when the body’s natural balance that keeps it under control is upset

Thrush always causes a discharge
False. Itching is the usual symptom of thrush and there is often no discharge at all, or just a slight discharge

Thrush is very smelly
False. If there is an odour, it is minimal and not unpleasant

Thrush can be prevented by douching the vagina
Very definitely false. Douching is squirting a soapy or antiseptic solution into the vagina to ‘cleanse’ it. There is no need to do this, because the vagina cleans itself very efficiently. In fact, douching has the opposite effect; it destroys the friendly bacteria, gets rid of the healthy acidity and damages the lining, allowing thrush and other infections to take hold easily

How do you know if you have thrush?
There are three main symptoms of thrush.

The commonest symptom of thrush is itching and/or soreness around the entrance of the vagina (vulva). The soreness means that you have a stinging sensation when you pass urine and that sex is uncomfortable.
There may also be a thick, whitish discharge (like cottage cheese), or a watery discharge. The discharge does not smell unpleasant.
The vulval area looks red, there may be cracks in the skin and the vaginal lips (labia) are often swollen.

It is very difficult to know if thrush is the cause of your problem without having a test, because these symptoms can also occur in other types of infection. For example, an infection in the bladder (cystitis) will also cause stinging when you pass urine, various infections can cause vaginal discharge or vulval soreness, and some skin diseases (which are not infections) can cause vaginal itching.

Researchers in the USA tested women who felt sure they had thrush, and were buying thrush medication from a grocery store or pharmacy (Obstetrics and Gynecology 2002;99:419–25). They found that only 33% had thrush as their only problem. Another 20% had thrush as well as a different infection that needed a different treatment, such as bacterial vaginosis or trichomoniasis.

This means that if you think you have thrush you have two possible courses of action.

You could see your doctor or to go to a genitourinary medicine clinic to check the diagnosis. If you have never had these symptoms before this is sensible.
You could buy thrush medication from a pharmacy. According to the American research, there would be a less than 50:50 chance that this would be the right treatment. So if the symptoms persist after the course of treatment, see a doctor for a proper check-up and do not just buy more thrush medication.

Treatment
Creams and pessaries. If you have thrush, the Candida will be on the skin of the vulva, and also in the vagina. Therefore you need:

an anti-thrush cream to deal with the Candida on the skin
an anti-thrush pessary to deal with the Candida in the vagina; a pessary is a specially shaped lump of anti-thrush medication for insertion into the vagina.

There are various types of anti-thrush creams and pessaries. Most contain ‘-azole’ drugs, such as clotrimazole, econazole, fenticonazole or miconazole. These drugs are very similar and are all more or less equally effective. Nystatin is another type of anti-Candida pessary; it may stain your clothes yellow.

Some of these treatments can be bought from pharmacies without a doctor’s prescription, in packs containing both cream and pessaries. Read the directions carefully, because some types of pessary (such as nystatin) have to be inserted every night for 2 weeks, but others need to be used for fewer days.

In about 15% of people, these treatments may cause a burning feeling or irritation soon after applying the cream.

Many anti-thrush creams and pessaries can damage condoms and contraceptive diaphragms.

Treatments that you swallow (oral treatments). Some special anti-thrush tablets and pills are now available, such as fluconazole and itraconazole, which can be used instead of creams and pessaries. These are called ‘oral treatments’. Oral treatments have to be prescribed by a doctor; do not try swallowing a pessary that is meant to be inserted in the vagina. Although oral treatments are simpler than creams and pessaries, they can have side effects, so most doctors prescribe them only for very troublesome thrush that keeps coming back.

Why do some people keep getting thrush?
A common scenario is that you develop thrush, you treat it with an anti-thrush cream or vaginal pessary, the symptoms disappear, and then a few weeks later they come back again. This is called ‘recurrent’ thrush. Doctors do not fully understand why some people suffer from recurrent thrush. There are three different theories.

The ‘gut theory’ says that Candida yeasts lurk in the lower part of the gut (rectum). When you use an anti-thrush cream, you get rid of thrush from the vulva (the area around the opening of the vagina). According to this theory, you later get a reinfection from your own gut. This theory was very popular in the 1970s, but most doctors no longer believe it, because clearing Candida from the gut (with a long course of tablets) does not prevent recurrent thrush.
The ‘sexual theory’ says that your partner reinfects you, even though he does not have any symptoms himself. It is true that about 20% of the partners of women with recurrent thrush have the same type of yeast in their mouth or on their fingers or genital area, but most do not have any. And scientific studies mainly show that treating her partner has no effect on the likelihood of a woman having recurrences.
The ‘vaginal relapse theory’ is the one believed by most doctors. It seems that treatment does not eliminate the Candida totally. Tiny numbers of the yeast remain. If the situation is right for them – for instance, the skin is moist and warm – they slowly multiply until there are enough to cause symptoms again.

What to do if you keep getting thrush
Check that you really do have thrush. If it usually goes away with anti-thrush treatment, it probably is thrush, but it is worth making sure. According to research from the University of Leeds (published in the journal Sexually Transmitted Infections in 2001), a third of women who attended a clinic because of recurrent thrush did not actually have thrush. There were other reasons for their symptoms.

To check whether or not you have thrush, you should visit your family doctor or local genitourinary medicine clinic to have a swab taken. The swab will be sent to a laboratory, which will be able to tell if there is Candida or similar yeasts. Although Candida is the usual cause of thrush, in about 5% of cases symptoms are due to a slightly different type of yeast, for which another treatment might be more effective. With recurrent thrush there is an even greater chance that it is an unusual type.

Look after yourself. It is crucial to make life as difficult as possible for the Candida yeasts, so take a look at our list of ‘Commonsense dos and don’ts’ for anyone with a vaginal or vulval problem. Avoid anything that might irritate the vulva, such as bubble baths, perfumed soaps, vaginal deodorants and douches. For sex, use a lubricant to lessen the chance of damage to the vulva and vagina.

Keep the vulval area dry. Candida yeasts like warm, moist places so dry carefully after bathing or showering. Avoid tight fitting or synthetic-fibre knickers – choose cotton.

Avoid long courses of antibiotics. The longer a course of antibiotics, the more likely it will lead to thrush. So if you need antibiotics, ask your doctor if a short course would be appropriate.

Natural remedies. If your recurrences are predictable, try a natural remedy to ward it off. For example, if your thrush usually comes before a period, on days 21–24 of your cycle, you could try a natural remedy starting on day 18. But remember that you can get a reaction to a natural remedy as easily as to a cream from the chemist, so stop straight away if that happens. Here are some popular natural remedies.

Gently smear a small amount of bio (‘live’) yoghurt over the vulva, and also put it inside the vagina. The easiest way to do this is to use a tampon with its applicator. Push the tampon back inside the applicator so you have a space for about a teaspoonful of yoghurt. Then insert the tampon in the usual way, which will push the yoghurt into the top of the vagina. Remove the tampon an hour later. However, a scientific study showed that yoghurt did not decrease thrush (British Medical Journal 2004;329:548).
Tea tree oil is another possibility. Dilute 20 drops or tea tree oil in half a cup of water, soak a tampon in this liquid and then insert it into the vagina. Change it as frequently as you would a normal tampon.
Buy some 9% acetic acid gel (Aci-Jel) from a pharmacy. It comes with its own applicator.

Do not bother trying a yeast-free or sugar-free diet. There is no evidence at all that these diets have any effect.

Ask your doctor about oral treatment. A 7-day or 14-day course of an anti-thrush drug taken by mouth (oral treatment) may deal with the Candida yeasts more thoroughly. After that, you could use the pessaries in the vagina once or twice a month to prevent the problem returning.

Oral treatments may have side effects, and are unsuitable if you are pregnant or trying to get pregnant.

Consider long-term medication if you are having many troublesome recurrences. Your doctor can prescribe oral treatment, which is usually taken once a week. After 6 months, you stop the treatment and wait and see if the thrush returns (New England Journal of Medicine 2004;351:876–83). However, taking a prescription drug regularly for a condition that is not seriously hazardous to your health is a big decision. It is not suitable if you are pregnant or trying to get pregnant. Discuss all the pros and cons very carefully with your doctor, and go for it only if your symptoms are really distressing.

Consider asking your partner to get treatment. Clinics do not usually advise that your partner is treated (because they do not believe in the ‘sexual theory’ of thrush). But if you have lots of recurrences, it might be worth asking your partner to be treated as well.

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