Five per cent of women experience thrush symptoms that don't go away.

February 15, 2016

By Cathy Watson, University of Melbourne. Images: iStock.

Imagine. You are on a two-week walking tour in Thailand and the unthinkable happens. An episode of vaginal thrush hits like a tsunami.

Every step is agonising and it’s hard to resist the urge to scratch your genitals incessantly. To make it worse, your tour guide is a male with limited English and there is no pharmacy within a day’s walk.

This is how Debra (not her real name) described her extreme experience to me at a consultation. Debra’s may sound like an extraordinary circumstance, yet women with vaginal thrush can suffer extraordinarily, no matter where they are at the time.

Although most women will have experienced one or more episodes of uncomplicated thrush that results in temporary discomfort, some suffer from recurrent episodes. The persistent physical symptoms of these can be shameful and often debilitating.

Uncomplicated thrush.

Uncomplicated thrush is common. About 75 per cent cent of women will have vaginal thrush in their lifetime.

Thrush is caused by a fungal infection (Candida albicans) that lives in the vagina, often without causing symptoms. Why some women develop symptoms is unclear. When symptoms do occur, they include itching, burning and a “cottage cheese-like” discharge.

Vaginal thrush mostly occurs during a woman’s reproductive years. It is uncommon before her first menstrual cycle and after menopause (when periods cease), so hormones are likely implicated.

Many have thrush at a particular time of the month, specifically before menstruation. It also often occurs following a course of antibiotics and is common in women with diabetes.

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Medications are available without a prescription so many women treat themselves. Treatment consists of antifungal creams or vaginal tablets, which are put inside the vagina with a special applicator.

There is also the choice of oral tablets, which are more expensive and not recommended for pregnant women.

But it’s important that women see their doctor if these treatments don’t work or symptoms recur. This is because they may be suffering from an entirely different infection, which requires different treatment.

Although women can effectively be treated with medications available over the counter, there are about five per cent for whom the symptoms recur or never go away.

Recurrent thrush.

Recurrent thrush refers to four or more diagnosed episodes of vaginal thrush within 12 months. Because the four episodes have to be identified with a swab test, research into this area is difficult and costly.

Compared with research into uncomplicated thrush, the published studies for recurrent thrush are few and of poorer quality. No research so far has found a cure that works for all women.

This also means we don’t know exactly how long women may go on having experiences of recurrent thrush. Anecdotal evidence shows episodes can come and go for many years.

For people like Debra, who forgot to pack “emergency supplies” before her trip, recurrent thrush can cause relentless itching, constant pain and embarrassment.

Some women need to take time off work. Others find their self-esteem and confidence suffers when the condition flares up. Some women may find sexual intercourse extremely painful and others have attributed relationship difficulties or breakdown to the condition.

Many have reported frustration about seeing doctors who “fob them off”, advising them to take another course of anti-fungal treatment, or telling them that they just have to “put up with it”.

"Recurrent thrush refers to four or more diagnosed episodes of vaginal thrush within 12 months." (iStock)

Recommended treatments

Some women benefit from long-term treatment, but relief remains elusive for others.

The only treatment of recurrent thrush supported by a large study is “suppression and maintenance” therapy. Symptoms are suppressed with a high dose of anti-fungal treatment followed by a maintenance dose (weekly or monthly) for up to six months to prevent remission.

Treatment is often inconsistent between practitioners. This perhaps reflects the lack of confidence in available guidelines, based on the above study.

In Australia, the Pharmaceutical Benefits Scheme (PBS) does not cover the recommended long-term treatment, making it unaffordable for many. If women use the vaginal creams or pessaries, the cost over a six-month period would be around A$600. Taking the oral treatment could set them back over A$900.

Some women are reluctant to take anti-fungal medications for long periods, as they can have some side-effects, including abdominal pain. Because of this and the expense, many turn to alternative therapies to combat thrush. (Post continues after gallery.)

Popular forms of birth control

Contraceptive pillThe Pillis the most popular form of birth control. There are two types: the combined pill, containing two hormones, and theprogestogen-only, or mini, pill, which only contains one female hormone. The combined pill works by preventing the ovary from releasing an egg each month. The mini pill changes the mucus at the entrance of the uterus, which stops sperm from entering. Both are 99.7% effective; however, they don't offer protection from STDs.

Intrauterine deviceIUDs are small, T-shaped devices that are inserted into the uterus by a doctor in order to prevent pregnancy. There are two types of IUD: copper, which affects the movement and survival of sperm in the womb while changing the lining of the womb;and hormonal, which releases progestogen (a synthetic version of the naturally-occurring hormone progesterone) into the uterus. Although IUDs have a success rate of more than 99%, only around 2% of Australian women currently use one.

CondomsThe male condom is a barrier contraception that prevents both pregnancy and the transmission of STDs. They work by collecting semen so it doesn't enter theman's partner's body. Condoms are 95 to 99% effective at preventing pregnancy.

The female condomThe female condom is a pre-lubricated sheath, which loosely fits inside of the vagina. The condom has a removable ring, which helps to insert the sheath and keep the condom in place. A larger ring remains on the outside to cover the opening of the vagina. They are designed to fit all women and can only to be used once. Due to misuse of the product it is only 79 per cent effective.

DiaphragmLike the male condom, the diaphragm is a barrier method of contraception. It's a shallow silicone dome that's inserted into the vagina andcovers the cervix, which is the entrance to the uterus. It's held in place by the pelvic muscles, and works by preventing sperm from entering the uterus. After sex, diaphragms need to remain in placefor another six hours, in which time the sperm inside the vagina die. This method is 88 to 94% effective at preventing pregnancy, although this rate increases with experience.

Birth control implantThis is a 4cm-longimplant that is inserted into a woman's upper arm, just under the skin, by a doctor. It releases a hormone called etonogestrel, which prevents ovulation and thickens the mucus in the cervix, which can stop sperm from entering. Contraceptive implants - usually sold as Implanon - are removed under anaesthetic every three years, and are close to 100% effective.

Vaginal ringVaginal rings are soft plastic rings that contain the same two hormones as the combined pill - oestrogen and progestogen. The ring is inserted into the vagina, where the hormones are absorbed into the body and then prevent the ovaries from releasing eggs. Once inside the ring can't be felt, and it needs replacing every three weeks (with one week's break in between). When used correctly, this method is more than 99% effective.

Depo ProveraDepo is a long lasting hormonal injection. The synthetic form of progesterone is administered every 12 to 14 weeks to woman, preventing pregnancy within this ongoing time period. The injection, which is given in the buttock or muscle of the upper arm, prevents ovulation and thickens the mucus in the cervix, helping to block sperm. The injections are 99 per cent effective but do not protect against STDs. Male contraceptive injections are currently being trialled

The morning after pillEmergency contraception (popularly referred to as the morning after pill) is used to prevent a pregnancy following unprotected sex. Other reasons include missing a contraceptive pill or a condom breaking. It is common in Australia to use the progestogen-only method. This entails a dosage of EC pills containing progestogen or the synthetic version. A doctor can prescribe the pill or they can be bought over the counter at a pharmacy without a prescription. Emergency contraceptionis 85 per cent effective in reducing the risk of pregnancy.

SterilisationSterilisation is a permanent form of contraception. For women there are two types of sterilisation: tubal ligation, in which clips are placed on the fallopian tubes, or tubal occlusion in which a device is inserted into the tubes. These methods work by preventing the sperm from reaching the egg. Tubal litigation is 99.5 per cent effective. The Vasectomy (for men) works by cutting and blocking the tubes called the vas deferens, preventing sperm from leaving the testicles. The chances of impregnation with a vasectomy are 1 in 1000.

Alternative treatments.

Although some women may find the folk remedy of yoghurt soothing, there is no strong evidence to support its use. Some recommend formulations such as aci-gel or vinegar to restore the normal pH of the vagina. But contrary to popular belief, the vaginal pH of women with thrush is usually normal.

Other natural treatments include tea tree oil and garlic. But using tea tree oil can lead to nasty allergic reactions, while garlic can burn.

Sometimes simple remedies such as ice packs applied to the area for up to ten minutes can bring relief. As alternative treatments, doctors usually recommend cotton underwear and avoiding feminine hygiene products, if possible.

Seeing a health professional who understands the complexities of this condition can be helpful, along with setting realistic expectations about management. Some hospitals have specialised vulval disorders clinics that women can attend with a doctor’s referral.

It is impossible to predict how long persistent thrush may last for individual women, but the good thing is most will respond to long-term therapy, and it will eventually ease.

Have you ever experienced recurrent thrush? What treatment was most effective for you?

Cathy Watson, Honorary Researcher, General Practice and Primary Health Care Academic Centre, University of Melbourne. This article was originally published on The Conversation. Read the original article.