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Key takeaways
Recurring yeast infections, defined as four or more in one year, are often due to sexual activity, incomplete treatment of a previous infection, drug-resistant yeast strains, misdiagnosis, or complicating conditions like diabetes.
The symptoms of chronic yeast infections include itching, red and swollen vulva, increased vaginal discharge, and odorless, white, clumpy discharge.
Treatment for chronic yeast infections may involve an initial course of topical vaginal azoles or oral fluconazole, followed by a maintenance phase with longer-term medication to prevent recurrence.
Preventative measures for recurring yeast infections include completing all prescribed treatments, practicing good genital hygiene, wearing breathable fabrics, managing blood sugar levels, and possibly incorporating probiotics into the diet.
Like most things in life, balance is key. This mantra holds true to a yeast (type of fungus) called Candida which normally lives on skin and inside different areas of the body like the mouth, throat, digestive tract, and vagina. Typically, Candida is present without causing any problems. Changes in hormones, medicines like antibiotics, or alterations in the immune system that weaken it may tip the balance and provide conditions which encourage overgrowth of Candida and can increase the risk of infections, including vaginal candidiasis. A single yeast infection is uncomfortable on its own, but recurring yeast infections can cause significant frustration with its interruption to day-to-date life. More than 50% of women older than 25 years of age have at least one episode of vulvovaginal candidiasis, or a vaginal yeast infection, in their lifetime; fewer than 5% of these women will experience a recurring, or chronic, yeast infection.
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What is a recurring yeast infection?
Yeast infections occur when too much of a naturally occurring yeast, most commonly Candida albicans, grows in the vagina. Recurring yeast infections are defined as those which occur four or more times in one year or at least three episodes unrelated to antibiotic therapy within one year. There is usually an underlying reason why a woman might suffer from recurring yeast infections and so getting to the root of that problem is crucial to effectively treat and eradicate the infection. Recurring yeast infections differ from persistent yeast infections in that patients will experience a period of symptom-free relief.
Causes of recurring yeast infections
There are a few possible reasons someone may deal with recurrent yeast infections:
1. Sexual activity
While yeast infections are not a sexually transmitted infection (STI), it is possible in some cases for sexual partners to pass the Candida to each other. To prevent this, use condoms or dental dams and practice good hygiene after sexual intercourse, such as showering. Avoid having sexual intercourse when one partner has a yeast infection.
2. The original yeast infection was not completely treated
Symptoms may disappear before the infection is fully treated. When this happens, the yeast infection will come back if treatment is stopped prior to the prescribed duration of therapy.
3. The yeast infection is caused by a drug-resistant strain
There are also strains of yeast that are more drug-resistant, which makes it harder to get rid of than others. While Candida albicans is the most commonly identified pathogen in patients with vulvovaginal candidiasis, other species of Candida like Candida tropicalis and Candida glabrata can cause infection and may require modifications to therapy.
4. It is not a yeast infection
There are other infections, such as bacterial vaginosis, or sexually transmitted infections (STIs), that may have similar symptoms. While an initial infection may be diagnosed over the phone, clinical evaluations of recurrent episodes is critical to rule out alternative causes like STIs and receive an accurate diagnosis. It is critical to visit a doctor, such as a gynecologist or primary care physician, when a yeast infection does not clear up, or when you’re not sure that what you’re dealing with is a yeast infection.
5. Other complicating conditions
Those with certain conditions, such as weakened immune systems and uncontrolled diabetes, are more susceptible to recurrent infections. Pregnant women may also be more susceptible. Uncontrolled diabetes may be a predisposing factor for recurrent yeast infections since high blood sugar levels encourage the ability of Candida species to bind to vaginal epithelial cells.
Noncompliance with treatment may result in concerns of what is mislabeled as a recurrent and is actually more representative of a persistent infection. Some of the over-the-counter therapies, including topical treatments, may be considered inconvenient or messy by women and therefore therapy not completed as indicated. Antibiotics are often implicated in recurrent vaginal candidiasis since they decrease protective vaginal flora, allowing overgrowth of yeast. The risk of a yeast infection increases with duration and frequency of antibiotic use.
Mechanical factors, like perspiration associated with tight-fitting clothing or underwear increases vaginal temperature and moisture, fostering overgrowth of Candida species.
Contraceptive methods may also promote recurrent vulvovaginal candidiasis by altering normal vaginal flora and increasing adherence of Candida species to vaginal epithelial cells. Women who have an intrauterine devices (IUDs) may be predisposed to vaginal colonization by Candida species, which could result in an infection.
Chronic yeast infection symptoms
Symptoms of chronic yeast infections don’t usually differ from a simple yeast infection, and include itching as the primary symptom. A woman may also suffer from a burning sensation in the tissue outside of the vagina, known as the vulva, which may intensify upon urination or during intercourse. The most common symptoms are listed below:
- Itching
- Red, swollen, and/or painful vulva
- Increased vaginal discharge
- Vaginal discharge that is white, clumpy and odorless
Chronic yeast infection treatment
Recurring or chronic yeast infections require a slightly different approach to management than a simple yeast infection. The first course of treatment for an uncomplicated yeast infection includes a short-course (single dose or once daily for three days) of any topical vaginal azole. It is important to note that OTC formulations must be taken as labeled, which may be seven to 14 days in duration. Alternatively, oral Diflucan (fluconazole) as a single dose of 150 mg may also be used for uncomplicated vulvovaginal candidiasis.
For recurrent infections, therapy is managed with both an induction and a maintenance phase in order to achieve a cure. In the induction phase, therapy options include a longer course of a vaginal azole (e.g., for seven to 14 days as opposed to one to three days), or oral Diflucan (fluconazole) taken every three days for three doses (100, 150, or 200 mg). Less common option for the induction phase might include a compounded boric acid capsule that is administered vaginally once daily for 14 days, or a clotrimazole vaginal insert once monthly for six months.
In the maintenance phase, which should begin immediately after induction and continue for six months, one might be prescribed once weekly oral fluconazole (100, 150, or 200 mg). In the United States, a less preferable option would be intermittent administration of a vaginal azole, administration of a compounded boric acid capsule for five days at the beginning of each menstrual cycle, or ketoconazole 100 mg once daily.
For fungal infections caused by a different type of yeast, like non-albicans Candida species, one might consider treatment with seven to 14 days of a non-fluconazole azole regimen or insertion of a compounded boric acid capsule vaginally once daily for three weeks.
Two newer antifungal medications were recently approved by the Food and Drug Administration (FDA) which may have benefit in the management and prophylaxis of recurrent yeast infections. Brexafemme (ibrexafungerp) is an oral triterpenoid antifungal approved for vulvovaginal candidiasis, and is currently under review for FDA-approval for prophylaxis of recurrent candidiasis. Vivjoa (oteseconazole) is a new oral azole antifungal approved specifically for recurrent vulvovaginal candidiasis. This medication would be reserved as a last resort for patients with recurrent yeast infections, and should only be used for patients who are known to be permanently infertile or who are postmenopausal as it is teratogenic in animals and can be detected in human tissues for up to two years following treatment. Two regimens for Vivjoa are approved, and include:
- Vivjoa 600 mg on day one, then 450 mg on day two, then (starting on day 14) 150 mg once weekly for 11 weeks; or
- Fluconazole every three days for three doses, followed by Vivjoa (150 mg once daily for seven days, then once weekly for 11 weeks).
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How to stop recurring yeast infections
Management of chronic yeast infections takes a little will-power and perseverance. Lifestyle changes may be warranted, especially if the infection is due to sexual activity or uncontrolled diabetes. Avoiding sexual intercourse while experiencing the symptoms of a yeast infection, and good blood sugar control, may stop recurring yeast infections if these are contributing factors. Homeostasis of healthy bacteria in the vaginal tract may also assist in stopping recurring vulvovaginal candidiasis; research suggests that ingestion of probiotics like Lactobacillus rhamnosus can help restore urogenital flora. Other considerations to prevent recurring yeast infections include:
- Complete the full indicated course of medication when treating a yeast infection
- Wear breathable fabrics, like cotton, that wick moisture away from the body to prevent an environment that allows yeast growth to thrive
- Practice good genital hygiene, which includes use of mild and unscented soaps to keep the vaginal area clean while avoiding douches and perfumed sprays, powders, or tampons
- Avoid a diet high in sugar
- Consider addition of probiotics, either in the form of supplementation or by eating yogurt with live bacterial cultures or fermented foods (e.g,, kimchi, kefir and kombucha)
- Consult with a healthcare provider at the first signs of persistent or recurrent symptoms to rule out alternative diagnoses or design an induction and maintenance regimen
Recurring yeast infections can be frustrating, but by taking steps to prevent infection you may be able to minimize the impact to your quality of life.