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YEAST INFECTIONS AND RECURRENT VULVOVAGINAL CANDIDIASIS (RVVC)

Yeast infections are a common gynecologic problem affecting 75% of women at least once in their lives. 40-50% will experience at least one repeat episode and 5% will develop chronic recurrent vulvovaginal candidiasis (RVVC); (4 or more confirmed episodes in 1 year).

 

Candida Albicans is the most common yeast. Non-albicans species may be increasing in frequency due to self treatment with short, over the counter (OTC) preparations. Signs and symptoms of yeast infections are: itching, especially worse in the evening, burning, swelling, redness, burning on urination (dysuria), increased urinary frequency, painful intercourse (dyspareunia), and/or white cottage cheese-like discharge with yeast-like or vinegar-like odor. Discharge with a yellow or green color, with a foul odor (fishy) is another problem and should be examined by the physician or nurse practitioner.

Up to 20% of normal women will culture positive for candida, yet have no symptoms. This is NORMAL. Candida lives in the vagina normally until some mechanism triggers its overgrowth:

  • pregnancy
  • diabetes
  • anemia
  • zinc deficiency
  • hypo or hyper thyroidism
  • vaginal trauma
  • prior to menses, cyclic
  • cytotoxic drug usage
  • steroid usage
  • radiotherapy or chemotherapy
  • high estrogen medication usage
  • hormone usage
  • immunosuppressive drug usage
  • antibiotic usage (especially tetracycline, cephalosporins, ampicillin-like compounds)
  • debilitating disease (i.e. leukemia)
  • obesity
  • biking excessively
  • use of certain contraceptive devices i.e. IUD or diaphragm w/ contraceptive jelly
  • digestion of large amounts of candy or yeast products
  • wearing of tight clothing or nylon underwear, spandex, bathing suits
  • frequent and/or traumatic intercourse
  • AIDS or HIV infection
  • Addison's disease
  • Cushing's disease

In normal women without any risk factors, reinfection from an extravaginal source and relapse due to inadequate therapy or an intestinal reservoir may lead to RVVC. Other such sources of candida include oral cavities, rectum, and in the ejaculate of male partners.

Self diagnosis and use of OTC medications assumes that once a woman has been previously diagnosed with this condition, she will then recognize it again on the basis of the symptoms above. Unfortunately, candida-like symptoms may be due to other organisms and therefore, OTC preparations will be ineffective. OR, if the patient has RVVC, imidazols like Monistat may lead to non candida albicans overgrowth and treatment failure due to other candida species requiring a different treatment.

Some studies have shown that in 2/3 cases, woman will misdiagnose RVVC. If the first course of OTC treatment is not effective (and please be sure to finish the ENTIRE course), or if you have 2 or more infections in a short time (few months), please call the office.


Drug Formulations and Doses Commonly Used to Treat RVVC

Nystatin

100,000 U vaginal tablets

100,000 u x 14 days

     

Clotrimazole

1% cream

5 g x 7-14 days

Gynelotrimin

100 mg vaginal tablet

100 mg x 7 days

Mycelex

100 mg vaginal tablet

200 mg x 3 days

 

500 mg vaginal tablet

500 mg x 1 dose

     

Miconazole

2% cream

5 g x 7 days

Monistat

100 mg vaginal suppository

100 mg x 7 days

 

200 mg vaginal suppository

200 mg x 3 days

 

1200 mg vaginal suppository

1200 mg x 1 dose

     

Butoconazole

3 pre filled applicators

1 applicator x 3 days

Femstat

   
     

Tioconazole

2% cream

5 g x 3 days

Vagistat

6.5% cream

5 g x 1 dose

     

Econazole

150 mg vaginal tablet

150 mg x 3 days

     

Terconazole

0.4% cream

5 g x 7 days

Terazol

0.8% cream

5 g x 3 days

 

80 mg vaginal suppository

80 mg x 3 days

     

Ketoconazole

200 mg oral tablet

400 mg x 5 days

     

Fluconazole

150 mg oral capsule

150 MG x 1 dose

     

Itraconazole

100 mg oral capsule

200 mg x 3 days

We prefer to treat VVC topically first - due to high efficiency (best to treat topical disorders topically) and low incidence of side effects. The most common local adverse reactions are burning, stinging, itching, irritation, and/or pain - symptoms are difficult to distinguish from a yeast infection itself.

Fluconazole 150 mg given orally is an alternative to topical treatment. However, oral antifungals may cause nausea, vomiting, abdominal pain, and/or diarrhea in 5% of patients. Other medications may be affected adversely while on fluconazole:

  • Antacids
  • Anticholinergics
  • Anticoagulants (increased PT)
  • Astemizole (cardiac , increased QT interval)
  • Cimetidine
  • Cyclosporine (increased level)
  • Digoxin
  • Diuretics
  • H2 antagonists (decreased level Azoic)
  • Isoniazid
  • Loratadine
  • Methylprednisolone
  • Oral contraceptives (break through bleeding)
  • Phenytoin (increased level)
  • Potassium
  • Rifampin
  • Sulfonylurea (hypoglycemia)
  • Terfenadine (cardiac - increased QT level)
  • Theophylline (increased level)

Ask your physician if you are a candidate for oral treatment and be sure to mention if you are on other medications. Some patients may benefit from low dose oral antifungal powders dissolved in water to prevent cyclic yeast infections (i.e. prior to menses). Ask your physician or practitioner. The mechanism by which this works is through eradication of intestinal reservoirs of candida.

BORIC ACID--an old remedy with a great success!!  Your vagina is generally a "self-cleaning oven" due to the presence of good bacteria called lactobacillus. Yogurt with live cultures of this organism is a great nutritional addition to your diet.  Boric acid will help to maintain the proper pH balance of the vagina.  Often this balance is disturbed by medications especially antibiotics and other factors.

Capsules of boric acid 300 mg can be inserted into the vagina daily and will re-acidify the vagina allowing the "good" lactobacillus to colonize and help prevent further yeast infections. You will need a prescription for this. In the past, it could be bought in a bottle and used as a douche.

To Prevent RVVC

  • Be examined during a RVVC infection to be sure it isn't something else
  • Wear cotton crotch underwear. Avoid pantyhose and tight fitting jeans and clothing which restrict air circulation to the vagina; keep your hands off. DO NOT SCRATCH! Try Benadryl at night if itching occurs. Boil or bleach-soak underwear overnight or microwave 5 minutes while very damp to kill the candida.
  • Wipe from front to back after a bowel movement to avoid carrying bacteria or yeast from the rectum into the vagina.
  • Avoid using vaginal sprays and deodorants, sanitary pads containing deodorant and scented or colored toilet tissue. Avoid bubble baths, bath oil, etc. You may soak in a clean tub with 1/2 cup baking soda.
  • If possible, abstain from intercourse while using treatment, OR always use a condom during treatment to avoid spreading this to your partner.
  • Do not douche unless your prescriber advises you to.
  • Don't borrow or share towels, wash cloths, bathing suits, or underwear.
  • Some women find that eating yogurt with active cultures or taking acidophilus capsules helps prevent vaginal yeast infections.
  • Decreasing intake of sweets, alcohol, caffeine, wines, and lactose (milk, yogurt, cottage cheese, artificial sweeteners containing lactose) may also help.
  • For RVVC, discuss having your partner examined for yeast.




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