Endometriosis UK
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Thrush - it’s a killer!

Ever since I was diagnosed with endo I’ve had recurring thrush - no treatments have helped. It’ll clear for a few weeks and then without fail come back again! It’s getting so depressing now and completely coming between my sex life with my long-term boyfriend. I wear cotton underwear, I don’t use fragranced shower/bath gel, I have very good hygiene down there.. I’m at the end of my tether with it now!

Has anyone else had the same problem and been successful in getting rid of it for good?!

Any advice would be appreciated. Thanks ladies xx

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I'm the complete same nothing I do ever gets rid of it! It to has got me down and it effects me being intimate with my partner. Wish I could help but I too am in the same boat, sorry and good luck x

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I used to have this before and found a good quality probiotic if I don't take them for a couple days I can feel it coming back also limit sugar and yeast make sure any supplements you get are yeast free that caught me off guard before. Wish you both luck in getting rid of this 💗🤗😘

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Same with me! My consultant recommended probiotic supplements and I was surprised it worked after struggling for so long.

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Have they made sure you don’t have diabetes? You can take an oral antifungal tablet once a week eg fluconazole.

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Oh god don’t say that!

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Sorry !!!! Of course you don’t have it but it can rarely be a cause of chronic thrush but ususally you would be sick too and many women get thrush a lot and it’s not diabetes!!!! Sorry to freak you out! Get your Gp to check it is thrush and then if it is you can take oral antifungals regularly to manage it.

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Google “ Terri Foran recurrent vaginal thrush”

And you should find a great article for gps about managing thrush ! Give it to your Gp!! I’m in Australia and Terri Foran is an expert in women’s health here. She wrote a great article for Australian doctor. I would send you the link g vaginal candidiasis

About 75% of women will experience at least one episode of vulvovaginal candidiasis during their lifetime.

To manage this common and distressing condition effectively, an understanding of the pathogenesis of vaginal candidiasis and a logical approach to therapy is needed.

Knowing the organisms

Yeasts from the Candida species are common commensals in the human mouth, gut and vagina. Although Candida albicans is the species identified in about 85% of cases of vaginal candidiasis, other medically significant species include C. glabrata, C. parapsilosis and C. tropicalis.

Most of the time, these yeasts appear as chains of oval-shaped cells, which reproduce by budding at one end.

However, under certain physiological conditions, the yeast becomes more active and this normally well-tolerated passenger becomes responsible for the condition known as candidiasis.

Making the diagnosis

Most women with uncomplicated vaginal candidiasis will present with a combination of two clinical features: a thick vaginal discharge and vaginal irritation.

Clinical examination usually reveals local inflammation of both the vulva and vagina, with a typical ‘cottage-cheese' discharge adherent to the vaginal walls and vulva.

However, some recurrent infections and those caused by non-albicans varieties may not display this typical appearance and swabs may be required to confirm the suspected diagnosis. For maximal yield, these swabs should always be obtained from low in the vagina rather than from the cervix.

Candida albicans survives best in an oestrogenised environment, so overgrowth of this organism is extremely uncommon in pre-pubertal girls and postmenopausal women who are not on HRT.

When candidal vaginitis does occur in a postmenopausal woman, it is more likely to be involve one of the non-albicans varieties of candida.1

Immune system compromise, as occurs in diabetes, pregnancy and with immunosuppressive therapy, can also dispose a woman to vaginal candidiasis — again, particularly of the non-albicans types.

Understanding the disease process

The most likely source for the candidal infection is a woman's own intestinal reserve, which can be inoculated into the vagina. Some women appear more susceptible to candidiasis due to individual variations in their own vaginal biofilm.

However, in general, the vaginal lactobacilli play an especially important role in preventing candidiasis as they secrete substances that hamper the development of the hyphae responsible for local epithelial invasion.2

Once epithelial invasion has occurred, the yeast manufactures proteases, which punch holes in the cellular membrane leading to a release of inflammatory substances and local oedema, as well as cell shedding. Once infection is established, the candida then converts local sugars into alcohol, which acts as a potent secondary irritant.

Triggers for vaginal candidiasis include: the disruption of the protective mucocutaneous barrier by douching; local allergens; and the minor abrasions that may occur during intercourse.

The use of broad-spectrum antibiotics that reduce the numbers of normally protective vaginal flora is often touted as a likely trigger and there are certainly studies that appear to support this inclusion.3

A higher carriage rate of candida in those women using a high-dose oestrogen-containing contraceptive pill was suggested by some early studies.4 However, the evidence is far less convincing for the low-dose pills in use today.5

Vaginal candidiasis is not considered to be a sexually transmitted infection and unless the partner is symptomatic, clinical trials have not shown any evidence that treating the partner will improve the rate of cure or reduce the interval to recurrence.

Managing the condition

The key to the management of vaginal candidiasis is the use of azoles, either topically or orally.

Topical azoles

Topical azoles are usually the first choice for treatment of uncomplicated vaginal candidiasis because they are relatively inexpensive and effective, and generally eliminate the possibility of systemic side effects (table 1).

Table 1. Topical vaginal azoles available in Australia6

AgentVehicleRecommendation

Clotrimazole1% cream5g for 6 days

2% cream5g for 3 days

10% cream5g single application

100mg pessary1 pessary for 6 days OR 2 pessaries for 3 days

500mg pessary1 pessary single application

Combination 500mg pessary and 1% cream1 pessary single application with application of cream to vulva bd for up to 4 days

Butoconazole2% cream5g for 3 days

Even though azoles are fungistatic rather than fungicidal, as 99% of C. albicans are destroyed within 24 hours of exposure to the drug, there is 80-90% clinical cure for most uncomplicated cases of acute vaginal candidiasis.6

Topical anti-fungal agents have been available in Australia as a non-prescription item for many years. Pessaries are often seen as more convenient and less messy to use than creams but may take longer to alleviate symptoms. Some commercial preparations now package a cream together with a pessary.

The non-albicans varieties of candida are less susceptible to azole therapy and when these species are present alone, or in combination with C. albicans, treatment failure is common.6 In this circumstance, although the older drug nystatin is no longer recommended as first-line treatment for C. albicans (as it has only a 60-80% cure rate), it remains significantly more effective than the modern azoles against non-albicans varieties.

Therefore, when these other varieties are cultured, a two-week course of topical nystatin should be considered as primary therapy. An alternative is the significantly more expensive compounded option of boric acid (92-98%) in a dose of 600mg in a gelatin pessary, daily for 14 days.

Single dose, topical anti-fungal therapy appears to be as effective as a prolonged course in the treatment of uncomplicated monilial vaginitis, although longer courses of 3-6 days are generally recommended for patients with recognised risk factors, such as pregnancy or immunosuppression.

If local irritation is severe, the addition of a 1% hydrocortisone ointment, applied externally to the vulva, for the first 2-3 days of treatment should be considered.

Oral azoles

The oral azoles include ketoconazole, fluconazole and itraconazole. All are presently contraindicated during pregnancy.

Ketoconazole is rarely used as a first-line therapy for uncomplicated vaginal candidiasis as it has been associated with idiosyncratic liver toxicity. However, both fluconazole and itraconazole are generally safe and well-tolerated drugs.

Fluconazole is presently available as a pharmacist-supplied drug in Australia. Table 2 shows recommended doses and dosages for the treatment of acute candidiasis.

Table 2. Oral anti-fungal agents for vaginal candidiasis

AgentFormulationRecommendation

Fluconazole (Diflucan)150mg tabletSingle dose

Ketoconazole (Nizoral)200mg tablet200-400mg for 5 days

Itraconazole100mg tablet200mg bd single day OR 200mg daily for 3 days

Topical or oral agents?

A Cochrane review published in 2007 concluded that no studies have indicated a clear superiority of oral over topical azoles in the treatment of uncomplicated vaginal candidiasis.7

Generally, oral azoles tend to be more expensive than the topical preparations and have the potential for systemic side effects and drug interactions. They are also less effective at providing initial local relief of symptoms and, for that reason, many manufacturers co-package them with a small amount of topical azole cream to be used on the vulva for the first 24-48 hours.

However, some studies indicate that many women prefer the convenience of short duration oral therapy.8 So, it seems likely that consumer preference will lead to an increase in the use of oral azoles in the future.

Dr Foran is a sexual health physician and co-ordinator of undergraduate and postgraduate courses in women's health at the University of NSW.

References

Fidel P, et al. Candida glabrata: a review of epidemiology, pathogenesis and clinical disease with comparison to C. albicans. Clinical Microbiology Reviews 1999; 12:80-96.

Narayanan TK, Toa GR. Beta-indoleethanol and beta-indolelactic acid production by Candida species: their antibacterial and autoantibiotic action. Antimicrobial Agents and Chemotherapy 1976; 9:375-80.

Spinillo A, et al. Effect of antibiotic use on the prevalence of symptomatic vulvovaginal candidiasis. American Journal of Obstetrics and Gynecology 1999; 180:14-17.

Working Group of the British Society for Medical Mycology. Management of genital candidiasis. BMJ 1995; 310:1241-44.

Davidson F, Oates JK. The pill does not cause ‘thrush'. British Journal of Obstetrics and Gynaecology 1985; 92:1265-66.

Sobel JD. Treatment of vaginal Candida infections. Expert Opinion on Pharmacotherapy 2002; 3:1059-65.

Nurbhai M, et al. Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database of Systematic Reviews 2007; Issue 4.

Tooley PJ. Treatment of vaginal candidosis — a UK patient survey 1989. British Journal of Clinical Practice (Supplement) 1990; 71:73-76.

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have you had your gp take swabs to check for any other imbalance there? I had some taken from the edges and further up and in the process they found I had cervical ectropion (cells from further up the cervix come down and appear at the base) causing it to become sensitive and sore so it will bleed a little upsetting the balance and causing thrush.

recurrent thrush, 3 times or more in any 6 month period should be checked by your gp.

Hope you find a solution; it can be so annoying, and makes you feel horrible, I know :(

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Hi, I had chronic recurring thrush which finally resolved when I got the Mirena coil. A very unexpected and welcome side effect. My conclusion is that thrush can be affected by hormones in a similar way to endo, although I’ve never met a doctor who thinks this.

For the years and years I struggled to manage it the only thing that helped was the candida diet. But it’s very restrictive and I found the thrush came back as soon as I stopped following it strictly. So not really a solution.

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