Thrush is the common name for “Vulvovaginal Candidiasis”. Some females are troubled with recurring Thrush symptoms. Recurrent Thrush is when there are four or more specific episodes of thrush in one year or atleast three episodes in one year unrelated to antibiotic therapy .

What is Thrush?
Thrush is a fungal infection caused by Candida species. Candida spp. grows best in warm, moist, airless parts of the body. Other common areas of the body that are prone to candidal infection besides vagina include the groin, the mouth, and the nappy area in babies.Vulvovaginal Candidiasis or vaginal thrush, commonly referred as “thrush” is the fungal infection of female genital tract.

The most common symptoms of vaginal thrush are

  • Thick, creamy white vaginal discharge
  • Itching, redness, pain and discomfort outside or inside the vagina.
  • Occasional pain or discomfort whilst having sex or whilst passing urine.

Sometimes the symptoms are minor and can clear on their own. Otherwise, simple over the counter anti-thrush topical creams or single oral fungal tablet is enough to clear the infection. But for a few females thrush can have a protracted course and symptoms can be recurrent.

What causes Recurrent Thrush ?
There are a few known causes of recurrence, most common causes include

  • Inadequately treated infection which causes persisting infection that is mislabeled as recurrence. Noncompliance with a treatment regimen such as not completing the entire course of antifungal therapy can cause persisting infection.
  • Infection with uncommon Candida species such as Candida Glabrata or Candida Tropicalis. Most common cause of vulvovaginal candidiasis is Candida Albicans and the common over the counter therapies are targetted to treat C. albicans infection. Occasionally the infection can be caused by Non-Albicans species which are not very sensitive to the common over the counter treatment options.
  • Antibiotic use. Frequent antibiotic use and/or prolonged antibiotic use increases the risk of vulvovaginal candidiasis. Antibiotic use decreases the protective vaginal flora which increases the risk of growth of candida species.
  • Oral Contraceptive Pill may increase the chances of recurrent thrush. According to one theory, Candida cells have oestrogen and progesterone receptors that, when stimulated, increase fungal growth.
  • Use of spermicidal jellies and creams can cause recurrent thrush by altering the vaginal flora and promoting candida growth.
  • Diabetes Mellitus can cause recurrent thrush. High Blood Sugar promotes the binding of candida to vaginal cells.
  • Pregnancy. Thrush occurs more commonly in pregnancy, and can be more difficult to clear. In pregnancy, a course of seven days of topical treatment(without the applicator) is usually advised to clear thrush
  • Immunodeficiency caused by HIV infection or other immunity lowering causes can also cause recurrent thrush.
  • Increased sweating due to tightly fitted clothes or poorly ventilated underwear can cause recurrent thrush by increasing local temperature and moisture.
  • Mechanical friction of the vulvovaginal area by clothing or with sexual intercourse may also predispose already colonized areas to infection.
  • Diet high in sugar is also suggested to increase the chances of recurrent thrush.

How to treat Recurrent Thrush?
Treatment of recurrent thrush can be very frustrating and disappointing because their is no specific protocols for treatment of recurrent thrush.Treatment is individualized based on effectiveness, convenience, potential side effects and cost. Sometimes, despite a prolonged course of treatment symptoms might still recur once the treatment is stopped.

If Thrush symptoms are recurrent, the most important first step is examination and investigation to rule out any other possible cause of symptoms. Investigations in the form of Potassium hydroxide (KOH) testing and/or fungal cultures can confirm infection with candida and type of species involved.

Below, I am outlining the most common ways if treating recurrent thrush

  • For infrequent recurrences a person can use the over the counter anti-thrush creams at the onset of symptoms. This modality of treatment is simplest and most cost-effective if recurrences are limited. Most common over the counter cream used is Clotrimazole. Most common over the counter oral treatment is 150mg of Fluconazole tablet orally taken once .
  • If infection with “Non-Albicans” Candida species is suspected, Terconazole vaginal cream is the agent of choice.
  • Sometimes females might need need a longer course of treatment for adequate symptom control which involves daily oral antifungal such as Fluconazole/ itraconazole usually for 2 week.
  • After the acute episode of recurrent vulvovaginal candidiasis has been treated, subsequent prophylaxis or maintenance therapy is essential. Current national and international guidelines for recurrent vulvovaginal candidiasis include initial suppression and long term maintenance (oral or vaginal) therapy. This involves initially high doses of antifungal agents (usually) for 2 weeks, followed by long term weekly or monthly therapy.

The most common agents used for initial suppression are

  • Vaginal cream every night such as clotrimazole 1% or nystatin.
  • Fluconazole 50 mg – 150mg orally, once daily
  • Itraconazole capsules 100 mg orally, once daily . Treatment duration varies from 2 weeks to 6 months.

Maintenance therapy can be weekly or monthly, most commonly done for 6 months. Most common maintenance regimen are

  • Fluconazole 150–300 mg orally, weekly
  • Itraconazole capsules 100–200 mg orally, weekly or
  • Clotrimazole 500 mg pessary intravaginally, once or twice weekly or
  • Nystatin 100 000 units/5 g vaginal cream one applicator intravaginally, weekly
  • Terconazole administered intravaginally once a week,
  • Fluconazole or Itraconazole administered orally once a month has sometimes shown to be effective as well. A monthly 150-mg dose of orally administered fluconazole or 200-400mg of Itraconazole has been shown to reduce the incidence of recurrences by 50 percent.

(Anti-fungal therapy can be very expensive and usually the treatment choice will depend on the most cost effective regimen for the person. Many women have recurrences once prophylaxis is discontinued. Thus, they may need to stay on medication for a longer period).

  • Boric acid, administered in a 600-mg vaginal suppository twice daily for two weeks and then daily during menstruation, has been effective in the treatment of women with resistant infection. Sometimes prolonged use of Boric acid can cause local irritation and possibility of intoxication. Boric Acid can also be effective in treating “Non Albicans species” Candida infection.
  • Sometimes a person might need to reassess the use of Oral Contraceptive Pill and either change to lower dose OCP or try a different mode of contraception.
  • Natural’ remedies for thrush include:
    Reducing and limited overall sugar intake.
  • Live yoghurt inserted into the vagina or adding vinegar or bicarbonate of soda to a bath to alter the acidity of the vagina.
  • Daily ingestion of yogurt containing Lactobacillus acidophilus
  • Increasing daily intake of “Probiotics” to improve the local flora which helps fight thrush infection. (At present there is little scientific evidence to show that these remedies work but some women may find that they help soothe their symptoms).