What is thrush? 

Vulvo vaginal candidiasis, otherwise known as thrush, can be recurrent, annoying, painful, upsetting and traumatising to women. It can make having sex uncomfortable, create irritating, smelly and excessive discharge and cause inordinate distress.  

Thrush is an infection of the vagina and vestibule that can spread outside the small labia, large labia, intercrural and perianal regions. 

Thrush is common, and usually relatively easy to treat with topical anti-yeast creams.  

Approximately 70‐75% of women will suffer from thrush, also called vulvovaginal candidiasis, at least once in our lifetime. But for those women who suffer remitting and relapsing thrush infection and healthy vaginal microbiome imbalance, this problem can be depressing and frustrating. This problem affects up to 5% of women. 

What species of Candida causes thrush? 

In pre-menopausal, pregnant, asymptomatic and healthy women Candida albicans is the predominant yeast species that causes thrush.  

Why does thrush happen?  

Thrush can be induced or promoted by various factors, including STIs, immune mechanisms, genetic susceptibilities, allergies, high blood glucose levels such as in diabetes or gestational diabetes, in response to the accidental upset of good vaginal bacteria after using antibiotics for any infection, psychosocial stress, fluctuation of female hormone levels such as oestrogens and sexual activity. 

However, despite this, with most episodes of thrush women cannot identify a single definable trigger. 

Life Stages and Thrush 

Thrush can affect women at any stage of their reproductive life but is most common prior to menopause in the reproductive years. Sexual activity and changing hormones including under the influence of hormonal contraception, together with genetic, lifestyle and other factors can contribute to a woman’s risk of developing a thrush infection. 

Using inappropriate products with the wrong pH in your vagina, as a lubricant, douche or moisturiser can contribute to your risk of developing thrush. A common mistake women make is to use inappropriate sexual lubricants such as coconut oil thinking this might be healthy due to a plethora of online misinformation on this topic. 

How does my doctor diagnose thrush?  

The diagnosis of thrush is usually based on clinical symptoms and microscopic detection of “pseudohyphae”, physical features of yeast organisms that can be seen under the microscope when your doctor sends a vaginal swab to be tested for thrush.  

Symptoms alone do not reliably identify thrush from other causes of vaginal irritation, including imbalances or infections caused by other organisms, skin and autoimmune conditions.  If you have suffered recurrent thrush that is hard to treat or resistant to first line medical therapies, diagnostics should include fungal culture with a goal of species identification.  

Aside from Candida Albicans, what other species of yeast can cause thrush?  

While the predominant species of yeast that causes thrush is Candida albicans, non‐albicans species that can also cause thrush include Candida glabrata, Candida tropicalis, Candida krusei and Candida parapsilosis. 

What are the medical treatments for acute thrush?  

Acute thrush can be treated with local (topical) anti-fungal agents including imidazole's, polyenes or ciclopirox olamine. These medical therapies can be delivered in the form of vaginal tablets, capsules or creams.  

Triazole antifungal medicines can also be prescribed orally, together with antifungal creams, for the treatment of the vagina and vulva.  

Antimycotics such as boric acid are generally well tolerated, and different regimens show similarly good results. Boric acid can also play a role as a preventative measure to reduce the chance of developing recurring thrush once an infection has cleared. 

Antiseptics are potentially effective but act against the physiological vaginal flora so are not generally recommended as a treatment for thrush.   

What if thrush causing yeast has been found incidentally but I don’t have symptoms? 

The yeast that causes thrush can live harmlessly and relatively harmoniously as a minority organism of a woman’s microbiome. Neither a woman with asymptomatic colonisation nor an asymptomatic sexual partner needs to be treated as in this scenario there is no evidence of benefit.   

Women with chronic recurrent Candida albicans vulvovaginitis can undergo dose‐reducing maintenance therapy with oral triazole medications. Unnecessary antimycotic therapies should always be avoided, and non‐albicans vaginitis should be treated with alternative antifungal agents.  

Alternative and complementary strategies to treat and prevent thrush:  

Boric acid is known for its antibacterial, antifungal, and antiviral activity. Boric acid also has antiseptic and astringent characteristics. Applied topically to the vagina and vulva boric acid can potentially help control fungal growth, relieve symptoms of itch, reduce inflammation and accelerate the healing and recovery process.  

Patients with symptomatic vaginitis who were treated with boric acid, described fewer symptoms followed by negative swab culture results for Candida species. It has been scientifically demonstrated that boric acid led to a high mycological eradication rate, with final healing/cure of chronic thrush in the majority of women who participated in research conducted by Sobel and Chaim. While boric acid is not a first line therapy for thrush infection, it is an evidence based, low risk preventer for women who suffer from recurrent thrush.  

If I am pregnant and give birth vaginally, can thrush harm my baby?  

Newborn babies can be infected by thrush passing through the birth canal. Vertical transmission of thrush can cause oral thrush and nappy area dermatitis of the newborn. Local treatment of a mother’s thrush is recommended if this occurs around the time of giving birth. Oral anti thrush agents are not generally utilised during pregnancy, but topical anti-thrush medication measures are considered to be safe during all stages of pregnancy. 

What are some tips to prevent thrush?  

• Equilibrium is a lubricant and intimate daily treatment that is both perfectly pH balanced to enhance the dominance of vaginal good bacteria (the lactobacilli) and contains boric acid to help soothe and with the goal to prevent episodes of relapsing/remitting recurrent thrush.  
• Diet: A balanced diet including reduced refined sugar, with increased consumption of vegetables, fruits and dairy products 
• Lifestyle: Avoid irritants, douching, pH inappropriate product use   
• Probiotics: functional foods and supplements containing probiotics and prebiotics may have a beneficial effect on genital inflammation 
• Avoid unnecessary antibiotic therapies 

 

References:  

Cooke G, Watson C, Deckx L, Pirotta M, Smith J, van Driel ML. Treatment for recurrent vulvovaginal candidiasis (thrush). Cochrane Database Syst Rev. 2022 Jan 10;1(1):CD009151. doi: 10.1002/14651858.CD009151.pub2. PMID: 35005777; PMCID: PMC8744138. 

Farr A, Effendy I, Frey Tirri B, Hof H, Mayser P, Petricevic L, Ruhnke M, Schaller M, Schaefer APA, Sustr V, Willinger B, Mendling W. Guideline: Vulvovaginal candidosis (AWMF 015/072, level S2k). Mycoses. 2021 Jun;64(6):583-602. doi: 10.1111/myc.13248. Epub 2021 Feb 27. PMID: 33529414; PMCID: PMC8248160. 

Denning DW, Kneale M, Sobel JD, Rautemaa‐Richardson R. Global burden of recurrent vulvovaginal candidiasis: a systematic review. Lancet Infect Dis. 2018;18(11):e339‐e347. 

Thais Chimati Felix DvDdBR, Reginaldo dos Santos Pedroso. Alternative and complementary therapies for vulvovaginal candidiasis. Folia Microbiol. 2019;2018(64):133‐141 

Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. 2003;189(5):1297‐1300. [DOI] [PubMed] [Google Scholar] 

Sobel JD, Chaim W. Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis. 1997;24(4):649‐652.  

Mizgier M, Jarzabek-Bielecka G, Mruczyk K, Kedzia W. The role of diet and probiotics in prevention and treatment of bacterial vaginosis and vulvovaginal candidiasis in adolescent girls and non-pregnant women. Ginekol Pol. 2020;91(7):412-416. doi: 10.5603/GP.2020.0070. PMID: 32779162. 

Parsapure R, Rahimiforushani A, Majlessi F, et al. Impact of Health-Promoting Educational Intervention on Lifestyle (Nutrition Behaviors, Physical Activity and Mental Health) Related to Vaginal Health Among Reproductive-Aged Women With Vaginitis. Iran Red Crescent Med J. 2016; 18(10): e37698, doi: 10.5812/ircmj.37698, indexed in Pubmed: 28184325.