Chronic Candidiasis (Yeast Infections)

Yeast infections/vulvovaginal candidiasis (VVC)

Almost all women at least once in their lives experience the uncomfortable symptoms of vaginal
itching, burning, and discharge. It is common wisdom that these symptoms are diagnostic of a
“yeast infection.”  However, recent medical studies have shown that the majority of women who
have these symptoms do not have a yeast infection.  However, if it isn’t a yeast infection, what
else might it be?  To answer this question we need to discuss the symptoms of itching, burning,
and discharge.

You feel terrible itching and burning. It feels like you have a thousand mosquito bites in your
vagina. When a mosquito bites you, it injects a chemical called histamine into the bite. Histamine
reacts on nearby nerve endings to cause the sensation of itching and burning. But, of course, you
didn’t get a thousand mosquito bites in your vagina, so what’s going on? Anything that causes
inflammation in the vagina causes your own body to release histamine. This leads to the
symptoms of itching and burning.

So what can cause inflammation? Any vaginal infection can cause inflammation. The most
common vaginal infection is not yeast, but is instead an infection caused by bacteria called
bacterial vaginosis. In addition, another organism called Trichomonas can cause vaginal
infections. But, infections are also not the only cause of inflammation. Perfumes and dyes in
soaps or bubble baths, spermacides or lubricants, laundry detergents and fabric softeners can also
cause inflammation, irritation, or allergic reactions that stimulate the release of histamine. Since
so many different conditions can cause these type of symptoms, it is very difficult for medically-
untrained women to correctly self diagnose the cause of her vaginal itching, burning, and
discharge.  As most women are aware of the diagnosis of a yeast infection, and they are not
aware of the other possible causes of these symptoms, they often mistakenly self diagnose a
yeast infection.

The term vaginitis refers to any infection or inflammation in the vagina. Studies have shown that
in addition to vulvovaginal candidiasis other common forms of vaginitis are bacterial vaginosis
and Trichomonas. Approximately 30 to 35% of all vaginitis is caused by an overgrowth of
bacteria in the vagina called bacterial vaginosis, 10% of all vaginitis is caused by Trichomonas,
10% is caused by inflammation due to chemicals or allergic reactions, and 20 to 25% of all
vaginitis is caused by yeast infections. Approximately 15 to 20% of all vaginitis is actually a
combination of two or more of the other types of vaginitis. As most women are aware of yeast
infections, but not aware of bacterial vaginosis and Trichomonas, there is a tendency for women
to consider vulvovaginal candidiasis for their vaginal symptoms and not the more common
diagnosis of bacterial vaginosis.

This fact was underscored by a study in the Journal of Obstetrics and Gynecology in 2002. In
this study ninety-five women were stopped in a pharmacy as they were about to purchase an
over-the-counter yeast medication. They were offered the opportunity to go to a doctor’s office
and have an accurate diagnosis made at that time. Of those ninety-five women who had self
diagnosed a yeast infection only 33% were actually found to have only a yeast infection. The
majority of women had either bacterial vaginosis or a mixed infection. Therefore they would not
have been treated with the over-the-counter yeast medication that they had planned to purchase.
As importantly, women who had been previously diagnosed with a yeast infection were no
more likely to be able to self diagnose a yeast infection than those women who had never been
told they had a prior yeast infection.

This study illustrates the fact that the symptoms of vaginitis are non-specific. An examination by
a healthcare profession is essential to make the accurate diagnosis. The diagnosis of a yeast
infection cannot be made over the phone by your doctor. Symptoms of itching, burning, and
“cottage cheese”-like discharge do not mean you have a yeast infection. Only a healthcare
professional has the diagnostic tools and the experience to make an accurate diagnosis, and this
must be done in person. To differentiate among the three most common types of vaginitis, a
physical examination should be performed. In addition a microscopic examination of the vaginal
secretions and measuring the pH of the vaginal secretions is absolutely essential. Additional tests
such as a culture or DNA testing are often necessary to make an accurate diagnosis.

When you do go to your healthcare provider’s office the first thing your healthcare provider
should do is ask you your symptoms. As we said before symptoms are generally non-specific to
yeast infections; however, some symptoms may give your doctor a clue as to what type of
vaginitis you have. Itching, soreness, and pain during intercourse are more likely to be a yeast
infection than bacterial vaginosis. Symptoms of a malodorous discharge without pain during sex
are more likely to be bacterial vaginosis, and symptoms of a malodorous vaginal discharge with
pain during sex are more likely to be Trichomonas. Next your healthcare provider should
perform a physical examination. Again there may be some clues on physical examination that
may point towards a yeast infection as opposed to  bacterial vaginosis or  Trichomonas.
Redness of the labia, swelling of the labia, and cracks or fissures of the labia are more likely to
be a yeast infection than bacterial vaginosis. A sticky-adherent discharge it is more likely to be  
bacterial vaginosis or Trichomonas. Next your healthcare provider will test the pH of the
secretions. A pH of 4 to 4.5 is more likely to be vulvovaginal candidiasis while a pH of greater
than 4.5 is more likely to be bacterial vaginosis or Trichomonas. However, as we pointed out
earlier approximately 15%-20% of all vaginitis is a mixed infection and therefore these “rules”
may not hold true.

The next thing your healthcare provider should do is perform a microscopic examination. This is
the quickest and cheapest test that your doctor can perform to make an accurate diagnosis of
vaginitis. Under the microscope we  may see yeast cells called hyphae.
Unfortunately, in about one third of all cases of culture proven yeast infection, no yeast are seen
under the microscope. If your healthcare provider is not able to accurately diagnose what type of
vaginitis you do have by evaluation of your vaginal secretions, it is essential that a culture be
performed. While all cultures do not give immediate diagnoses, they are very accurate and will
help prevent incorrect treatment.

If your healthcare provider does diagnose a true yeast infection, there are many different
treatment options. There are both over-the-counter and prescription
topical treatments  and  there is an oral medication,
fluconazole, approved for the treatment of vulvovaginal yeast infections. The topical treatments
come in many forms including vaginal creams, suppositories, and tablets. There are single-dose,
three-day, or seven-day treatment regimens available.

In summary when a women encounters itching, burning, and discharge there may be one of several  possible causes of these
symptoms. Therefore, it is essential that she go to a healthcare provider and get an accurate
diagnosis before beginning treatment. If she is accurately diagnosed with a yeast infection, then the treatments are very effective.