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Summary:

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• Thrush is a fungal infection that is treated with antifungals. It's also called a yeast infection/candida infection.

• Symptoms include: burning, irritation, sometimes itching with a cottage cheese discharge

• Check the strain and susceptibility with your doctor to make sure the drugs being used will work, especially if you get them frequently (see 'Repeated thrush' section) 

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Intro

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Thrush, also known as a candida or yeast infection, is a common condition caused by a fungus. ​

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Infections can take place in the mouth or anywhere on the skin but for women it often takes hold in the vagina.

 

Candida grows best in warm moist areas and so pathological overgrowth occurs when the micriobiome of the vagina becomes unbalanced. 

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Candida is most often a commensal organism, that means it lives in the body without causing problems unless conditions allow it to replicate excessively.

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"Candida exists without causing symptoms in about 20 to 50% of healthy women"

 

Candida exists without causing symptoms in about 20 to 50% of healthy women (McClelland RS, et al. 2009 referenced in Konolad 2019). That means it lives in the vaginal microbiome without causing harm and doesn't necessarily always need to be treated despite being identified on a swab. 

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Vaginal Thrush​

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It is unknown why the vaginal mucosa is particularly susceptible to candida overgrowth and more research is needed in this area.

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"Less than 1% of worldwide health funds are spent on women's health"

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Less than 1% of worldwide health funds are spent on women's health and our understanding (or lack of) is linked to gender inequalities in medicine.

 

Thrush strains

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90% of infections are caused by Candida albicans strain. However infections can also be started by: Candida parapsilosis, Candida galbrata, Candida dublinensis, Candida tropicalis, Candida krusei and Saccharomyces cerevisiae.

 

A new species: Candida auris has also been detected but is more associated with systemic infections than vaginal and is multiple drug resistant. 

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Thrush treatment

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Candida Albicans usually responds to azole drugs like fluconazole and clotrimazole. However if you have repeated infections, it can eventually develop resistance and needs to be treated with second-line therapies like boric acid suppositories, nystatin or intraconazole. 

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"Non-albicans strains are more azole resistant"

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Non-albicans strains are more azole resistant and require long-term treatment with second-line drugs like Nystatin or boric acid. A new drug released in America: Brexafemme is also an oral drug that can be used in azole-resistant cases. The license is owned by GSK and won't be eligible for release in Europe for a number of years – watch this space. 

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Whilst evidence of probiotics to combat a thrush infection is mixed, consumption of lactobacilli strains has been associated with an increase in protective bacteria that usually keep candida numbers in check (Zahedifard 2023). This must be in combination with anti-fungal treatment and probiotics alone will not treat a candida infection. 

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Symptoms​

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Different women experience symptoms differently and to varying degrees of irritation. However key symptoms are as follows:

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– Raw burning in the vulva

– Intense burning in the vagina

– White cottage cheese discharge (although this can be absent)

– Itching in the vulvovaginal region

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Risk Factors

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Environmental changes that allow candida overgrowth are:

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• Antibiotic use – by killing off lactobacilli, Candida has no competition for sugars and can easily overgrow. 

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• High sugar diet – eating foods and drinks filled with simple sugars like sweets, chocolate, fizzy drinks and alcohol over a sustained period allows for candida overgrowth. People who suffer from diabetes are at increased risk due to more freely available sugar in the blood. 

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• Immune system compromise. This can be brought on by sustained psychological stress or having a break after an intense work period. HIV/ AIDs patients have a higher risk of candida infection. Alcohol consumption also increases your risk of thrush.  

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• Contraceptive use. The coil (both hormonal and copper) is associated with an increase risk of yeast infections as they allow biofilm formation and the microbe to evade the immune system. Contraceptives that increase levels of oestrogen have also been found to increase the risk of thrush as oestrogen allows sugar deposits in the vaginal wall. 

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• Lifestyle factors. Many mainstream lubricants contain glycerine - sugar which increases the risk of thrush. Women should use brands without sugar like YES which contain no extra sugar. Douching, bubble baths/ soaks and femine products are associated with decrease numbers of lactobacilli which keep candida numbers in check. Certain clothes promote moistness in the vagina which promotes candida growth. Cotton underwear and loose fitting garments help prevent overgrowth. ​

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Male partners​

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Women with vaginal yeast infections can often pass on their infection to partners. ​

​Men should be treated if symptomatic to ensure couples don't pass the infection back and forth to one another. 

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