by Dr.Agilan Arjunan, Fertility Specialist & Gynaecologist, evelyn Women Specialist Clinic, Petaling Jaya (Malaysia)
A recurrent vaginal irritation or infection can be a nightmare for some women. Despite various treatment regimes from different health professionals the symptoms may not disappear and instead reoccur. Days persist with discomfort and sleepless nights. Therefore, it is vital to understand this condition in pursuit for an effective solution.
A common reason for recurrent vaginal irritation is a fungal infection of the vagina, known as Vulvovaginal Candidiasis. When it is recurrent in nature, it is known as recurrent vulvovaginal candidiasis (RVVC). In fact, vulvovaginal candidiasis is considered the second most common genital infection in women after bacterial vaginosis. At least three quarter of all women would have experienced at least one episode of this vaginal fungal infection in their lifetime.
What is it?
A fungal or yeast infection is caused mainly by the Candida species, known as Candidiasis. Actually, yeast is present on your skin, gut, respiratory tract and in the vagina. Usually, a trigger causes the yeast to overgrow. However, in majority of women, no trigger can be identified.
Why Do I get It?
As mentioned, in majority of women, no trigger factor can be identified. However, for an identifiable trigger factor, it is usually related to the individual’s health status or lifestyle. One of the main trigger is over exposure to the female hormone, oestrogen. This happens during puberty, pregnancy and during consumption of hormonal birth control pills or hormone replacement therapy in menopausal women. The change in oestrogen hormonal levels upsets the body’s natural balance, including the normal flora or healthy ‘bacteria’ balance in the vagina that keeps everything under control.
Consumption of a course of antibiotics during an illness period such as a sore throat or lung infection can be a trigger too. Exposure of a broad-spectrum antibiotic can change the vaginal normal bacterial harmony and predispose the women for vaginal yeast overgrowth.
The other common but unknown to many is the unintentional usage of irritants such as perfumed bath soap, wet wipes and chemically strong fabric conditioners. Even usage of contraceptive spermicidal gels can also predispose to yeast infection in some woman. Underlying uncontrolled Diabetes Mellitus and iron deficiency anaemia predisposes a woman to recurrent yeast infection too.
Why this is important for me?
Recurrent vaginal yeast infection, a chronic or a long-term infection, can tremendously affect quality of live and productivity. It has a negative effect on interpersonal relationship especially with the sexual partner. This can lead to psychosexual problems, not to mention the amount of psychological impact that it causes because the woman may feel “conscious’ with loss of self-esteem and self-confidence in their relationship.
How Do I know I have it?
The mild form of the infection may not cause vaginal discharge or irritation. However, if the infection worsen, the first symptom that the woman may feel is vaginal irritation or itchiness which may persist for days or weeks. She may start noticing a vaginal discharge. The discharge is usually described as white curdy or thin. She will then develop soreness or a burning sensation in the vagina or on the skin of her vulva. In more severe infection, due to the inflammation, the woman develops tears or crack on the vulva, called fissure. In a long-standing infection, the vulval area will become swollen with redness causing pain.
How to treat it?
The first step in the treatment of recurrent vaginal yeast infection is to stop self-diagnosis and self-treatment. This practice may lead to delay in instituting the appropriate treatment regime or worse, it may exaggerate the situation by inappropriate consumption of unnecessary antibiotics.
Meet your doctor who will take a thorough medical history including your past medications that you have taken to treat the infection, over the counter medications and complementary or alternative therapy. Your doctor will also try to identify your trigger factors and other symptoms that may suggest a different diagnosis for your underlying condition, such as Bacterial Vaginosis or Trichomonas vaginalis infections.
A pelvic examination will be performed using a vaginal speculum (similar to the type of examination you do for your cervical smear test). A high vaginal swab test will be performed. This is when the doctor takes a sample of the discharge to be sent to the laboratory to confirm and identify the yeast. Sometimes bacterial infection co-exists along with a yeast infection. In this scenario, the woman may need anti-fungal treatment along with the appropriate antibiotics as suggested by the high vaginal swab test report.
In recurrent vaginal yeast infection, based on your risk factors, your doctor may screen for Diabetes Mellitus and anaemia.
The first line treatment for vaginal yeast infection is a vaginal anti-fungal pessary with or without oral anti-fungal tablets. In recurrent infections, a prolonged course of treatment up to 6 months may be needed. In resistant infections, supplementary therapies in the form of anti-histamine medication and oral probiotics to improve gut and skin flora will be considered.
Anything else I can do?
You need to avoid known trigger factors that increase the risk for the fungal infection. Avoid local irritants such as perfumed bath soaps, shampoo, bubble bath, fabric softener and wet wipes. Avoid tight fitting garments that might irritate the genital area. Consider using a breathable underwear.
Consider avoiding pads, which prevents aeration, until the infection is under control. Avoid vaginal douching because it is associated with recurrent vaginal infections by disrupting normal vaginal flora. Do not wash your vulval or vaginal area too often. Consider washing once or twice a day, at least until the infection is under control.
If you are using male condom as your sole contraception method during an intercourse, then it is advisable to consider other options for contraception because vaginal anti-fungal treatment may affect the efficacy of contraception offered by condom method.
Infection in Pregnancy and during breast feeding
Up to one-third of pregnant women have asymptomatic vaginal yeast infection. Symptomatic yeast infection is common in pregnancy. The safety of anti-fungal treatment in pregnancy is not well established. However, epidemiological studies of thousands of women taking short courses of anti-fungal treatment shows no increase in fetal malformation.
The current recommendation is to use vaginal anti-fungal pessary (Clotrimazole 500mg) daily for 4 to 7 days. The treatment duration can be longer for recurrent infections.
Vaginal yeast infection, either acute or recurrent, can be best treated by a combination of identifying the correct diagnosis, appropriate initiation of treatment by a medical doctor and avoiding trigger factors as much as possible. Thus, ensuring a peaceful and blissful sleep at night.