Vaginal Thrush

Definition/diagnostic criteria Vaginal thrush, also known as vulvovaginal candidiasis (VVC), is a common fungal infection predominantly caused by Candida albicans. The diagnostic criteria for vaginal thrush include the presence of characteristic symptoms of itching, soreness, and abnormal discharge, along with the demonstration of yeast or hyphal forms of Candida species on microscopy of vaginal swabs or secretions.

Recurrent VVC is defined as four or more symptomatic episodes over a 12-month period, with at least 2 of these confirmed by microscopy or culture.

Epidemiology Vaginal thrush is a prevalent condition among women of reproductive age in the UK. It is estimated that approximately 75% of women will experience at least one episode of vaginal thrush during their lifetime. Recurrent episodes are not uncommon, affecting up to 5% of women. Factors that increase the risk of developing vaginal thrush include pregnancy, uncontrolled diabetes, immunosuppression, and the use of certain medications, such as broad-spectrum antibiotics and corticosteroids.

Diagnosis

Clinical features Vaginal candidiasis is characterized by a white, odourless, curdy discharge that may be associated with vulval itching and superficial soreness.

It is essential to consider other possible diagnoses, such as bacterial vaginosis or sexually transmitted infections (STIs).

Investigations Examination may be omitted and empirical treatment started for women with characteristic symptoms of vaginal candidiasis at low risk of STI.

Examination and high vaginal swabs should be considered if there is a risk of STI, if the symptoms have developed following a gynaecological procedure or if there are frequent or recurrent episodes.

In recurrent VVC blood tests for underlying causes (e.g. HbA1c) should be considered.

Treatment

Acute VVC Recommended Regimen:

Topical antifungals: Clotrimazole pessary 500mg as a single dose, intravaginally +/- clotrimazole cream.

Or Oral antifungals: Fluconazole (150 mg) as a single oral dose (avoid in pregnancy and breastfeeding)

Recurrent VVC Recommended Regimen:

Induction: Fluconazole 150mg orally every 72 hours x 3 doses

Maintenance: fluconazole 150mg orally once a week for 6 months

Prognosis Vaginal thrush is usually a self-limiting condition. Most women experience rapid relief from symptoms within a few days of starting treatment. However, recurrent episodes may occur, and it is essential to address underlying risk factors such as uncontrolled diabetes or immunosuppression. Long-term prophylactic treatment is not recommended routinely but may be considered in recurrent cases with significant impact on a woman’s quality of life.