II. Epidemiology

  1. Candida Vulvovaginitis accounts for 45% of Vaginitis
  2. Candida is cultured in 20-50% asymptomatic women
  3. Vaginitis often self diagnosed incorrectly

III. Etiology

  1. Acute: Candida albicans (90%)
    1. Normal commensal organism in vagina
    2. Infection when Corynebacterium suppressed
  2. Recurrent Vulvovaginal Candidiasis (4 or more episodes in a year)
    1. Candida glabrata (increasing Incidence, now 15%)
    2. Candida tropicalis
    3. Candida parapsilosis
    4. Candida krusei (responds to Topical Antifungals, but not to Fluconazole)
    5. Saccharomyces cerevisiae

IV. Risk Factors

  1. Immunosuppression
    1. Diabetes Mellitus (esp. Uncontrolled)
    2. Depressed cell mediated Immunity (e.g. HIV or AIDS)
  2. Medications
    1. Corticosteroids
    2. Immunosuppressant Medications
    3. Broad spectrum antibiotics
    4. Oral Contraceptives
      1. Increases frequency of Candida carrier state
      2. Does not increase symptomatic Vulvovaginitis
  3. Heat and moisture retaining clothing (e.g. nylon)
  4. Pregnancy (and other hyperestrogenic states)
  5. Premenstrual phase of the Menstrual Cycle
  6. Obesity

V. Symptoms

  1. Asymptomatic in 20-50% of women
  2. Intense vaginal or Vulvar Pruritus (50% of cases)
  3. Vulvar Burning, soreness, or irritation
  4. Thick white curd-like or "cottage cheese" discharge
  5. No odor
  6. Dyspareunia
  7. Dysuria (33% of cases)

VI. Signs

  1. Adherent white cottage-cheese discharge in vagina
    1. Sensitivity: 50%
    2. Specificity: 90%
  2. Vulvar erythema and edema (24% of cases)

VII. Labs: Initial

  1. KOH Preparation (10%)
    1. Test Sensitivity: 50%
    2. Pseudohyphae or budding yeast forms
    3. GynVaginitisYeast.jpg
  2. Vaginal pH <4.5 (Normal acidity)
  3. Absent Amine odor
  4. White Blood Cells not increased
  5. Wet-Prep is not sensitive or specific for yeast
    1. Bornstein (2001) Infect Dis Obstet Gynecol 9:105-11 [PubMed]
  6. Candida on Pap Smear
    1. Specific but very low Test Sensitivity

VIII. Labs: Complicated cases

  1. Indications: Complicated Vulvovaginal Candidiasis
    1. Recurrent candida Vaginitis (4 or more episodes in a year) OR
    2. Severe candida infections OR
    3. Immunocompromised patients (AIDS, poorly controlled Diabetes Mellitus)
  2. Fungal Culture positive
    1. Fungal Culture is rarely performed in typical cases (fungal PCR preferred)
    2. Fungal Culture may be very helpful in complicated cases
      1. Confirm asymptomatic carrier of vaginal Candida
      2. Identify cause of recurrent Vaginitis
  3. DNA probe or PCR for candida
    1. Consider in cases refractory to standard therapy

IX. Differential Diagnosis (Consider for refractory cases)

  1. Other Vaginitis cause
    1. Bacterial Vaginosis
    2. TrichomonasVaginitis
  2. Infectious Cervicitis (Sexually Transmitted Disease)
  3. Allergic Vaginitis or Vulvitis
  4. Vulvodynia
  5. Herpes Simplex Virus
    1. HSV presents with unilateral painful lesions
    2. Contrast with bilateral, symmetric involvement in Candida Vulvovaginitis

X. Management: OTC Local First-Line Agents

  1. Precautions
    1. In pregnancy, limit to topical azole preparations (Miconazole, Clotrimazole) used for 7 days (lower concentrations)
  2. Miconazole (Monistat)
    1. Miconazole (Monistat-7) 2% cream PV qhs for 7 days
    2. Miconazole (Monistat-3) 4% cream, 5 g PV qhs for 3 days
    3. Miconazole Vag tabs 100mg PV qhs for 7 days
    4. Miconazole (Monistat-3) 200mg PV qhs for 3 days
    5. Miconazole 1200 mg vaginal tab PV qhs, 1 dose
  3. Clotrimazole (Gyn-Lotrimin, Mycelex G)
    1. Clotrimazole 1% cream qhs for 7 days
    2. Clotrimazole 2% cream qhs for 3 days
    3. Clotrimazole 200 mg vaginal tab PV qhs for 3 days
    4. Clotrimazole 100 mg vaginal tab PV qhs for 7 days
    5. Clotrimazole 500 mg vaginal tab PV qhs, 1 dose
  4. Terconazole (Newer, binds better to Candida)
    1. Vagistat-1 6.5% ointment, 5 g intravaginally once
      1. Highly effective and less irritating than creams

XI. Management: Prescription Local First-Line Agents

  1. Butoconazole (Femstat)
    1. Mycelex-3 5g of 2% Cream PV QHS for 3 days
    2. Gynezole-1 (sustained release, bioadhesive) 5 g of 2% cream once intravaginally
  2. Terconazole (Newer, binds better to Candida)
    1. Terazol 80 mg vaginal suppository PV for 3 days
    2. Terazol-3 (0.8%) 5 g vaginal cream for 3 days
    3. Terazol-7 (0.4%) 5 g vaginal cream qhs for 7 days
  3. Nystatin
    1. Nystatin vaginal tablet (100,000 unit) PV daily for 14 days
    2. Nystatin ointment (100,000 units/g)
      1. Ointments are less irritating than creams

XII. Management: Oral Agents

  1. Fluconazole 150 mg PO for 1 dose
    1. As effective as Clotrimazole PV
    2. Do not use in pregnancy
      1. Evidence of Miscarriage risk, with even 1-2 doses
      2. Mølgaard-Nielsen (2016) JAMA 315(1):58-67 +PMID:26746458 [PubMed]
    3. Consider repeat scheduled treatment for persistent symptoms
      1. Consider prescribing Fluconazole 150 mg every 3 days for up to 3 doses for persistent Vaginitis symptoms
    4. Symptom improvement delayed for 24 hours with Fluconazole
      1. Consider concurrently treating with Nystatin ointment (100,000 units) for the first several days (least irritating)
    5. Higher mycologic cure rates in the short term (NNT 30) and long term (NNT 19) compared with intravaginal agents
    6. References
      1. (1994) Med Lett Drugs Ther 36(631): 1-2 [PubMed]
      2. Denison (2020) Cochrane Database Syst Rev (8): CD002845 [PubMed]
  2. Brexafemme (Ibrexafungerp)
    1. Dosing: 150 mg tablet taken in 2 doses at 12 hours apart
    2. Consider in recurrent candida Yeast Vaginitis refractory to repeat Fluconazole dosing
    3. Cost is nearly 50 fold higher than generic Fluconazole (approxmately $500 for 2 doses)
    4. Marketed as fungicidal against yeast (in contrast to fungistatic azoles such as Fluconazole, Clotrimazole)
      1. However, in practice, first-line azoles are 80-90% effective for definitive resolution
    5. References
      1. (2021) Presc Lett 28(9): 49-50

XIII. Management: Recurrent or resistant Treatment

  1. Precautions
    1. Avoid treating asymptomatic carriers (may be normal flora in some patients)
    2. Consider risk factors above
  2. Any of above intravaginal meds for 14-21 days
    1. Consider maintenance after initial daily regimen
    2. Maintenance: Repeat application once weekly
      1. Consider using monthly at time of Menses
    3. Consider Terconazole (see above)
      1. More effective against other candida species
  3. Fluconazole (Diflucan)
    1. See below for maintenance protocol
    2. Less effective for non-albicans Candida
    3. Dose 1: 150 mg orally
    4. Dose 2: 150 mg PO at 72 hours after first dose
    5. Consider a 3rd dose at 72 hours after second
    6. Sobel (2001) Am J Obstet Gynecol 185:363-9 [PubMed]
  4. Other options (many with increased toxicity and risk)
    1. Ketoconazole (Nizoral) 200mg PO bid for 5-14 days
    2. Itraconazole (Sporanox) 200 mg PO qd for 3 days
    3. Gentian Violet vaginal staining 1-2x (Office charge)
    4. Boric Acid 600 mg vaginal tab bid for 14 days
      1. Use is controversial, but may be considered in refractory non-albicans candidal infection
      2. Sobel (2003) Am J Obstet Gynecol 189(5): 1297-1300 [PubMed]
    5. Flucytosine (Ancobon) cream applied to affected area

XIV. Management: Prophylaxis (more recent protocol)

  1. Indication
    1. Four or mor yeast infections per year
  2. Initial treatment
    1. Fluconazole (Diflucan) 150 mg PO q3 days for 3 doses
  3. Maintenance
    1. Fluconazole (Diflucan) 150 mg PO each week
    2. Monitor liver enzymes (consider q1-2 months)
  4. Efficacy
    1. Suppression while on treatment: 90%
    2. Following treatment: Infection recurs in 60%
  5. References
    1. Sobel (2004) N Engl J Med 351:876-83 [PubMed]

XV. Management: Prophylaxis (old protocol)

  1. Protocol for 6 month maintenance regimen
    1. Start with 2 week recurrent treatment option above
    2. Follow treatment with prophylaxis option below
    3. Fungal Culture and exam timing
      1. Baseline
      2. Two weeks (after treatment regimen above)
      3. Three months
      4. Six months (when stopping prophylaxis)
  2. Medications
    1. Clotrimazole 500 mg vaginal tab weekly to montly
    2. Fluconazole 150 mg orally once weekly to monthly
    3. Miconazole 100 mg vaginal tab qhs twice weekly
    4. Avoid oral Ketoconazole due to hepatotoxicity

XVI. Prevention

  1. Control predisposing condition (e.g. Diabetes Mellitus)
  2. Reduce predisposing medications (e.g. Corticosteroid)
  3. Avoid moisture-retaining products near vagina
    1. Nylon underwear
    2. Panty-liners
    3. Vaginal Lubricants or Spermicides
  4. Lactobacillus (Probiotic) is not effective
    1. Does not prevent post-antibiotic Vaginitis
    2. Pirotta (2004) BMJ 329:548-51 [PubMed]

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Ontology: Candidiasis, Vulvovaginal (C0700345)

Definition (NCI) Infection of the vulva and vagina with a fungus of the genus CANDIDA. It is a disease associated with HIV infection.
Definition (MSH) Infection of the VULVA and VAGINA with a fungus of the genus CANDIDA.
Concepts Disease or Syndrome (T047)
MSH D002181
ICD9 112.1
ICD10 B37.3
SnomedCT 154404004, 266155003, 187009004, 72605008
English Candidiasis, Vulvovaginal, Moniliasis, Vulvovaginal, Vulvovaginal Candidiases, Vulvovaginal Moniliases, Vulvovaginal Moniliasis, Candidiasis of vulva and vagina, Candidal vulvovaginitis NOS, VULVOVAGINAL CANDIDIASIS, candidal vulvovaginitis (diagnosis), candidal vulvovaginitis, Candida albicans vulvovaginitis, Vulvovaginal candida, Vulvovaginal candidiasis, Candidiasis, Vulvovaginal [Disease/Finding], candidiasis vagina vulva, monilial vulvovaginitis, vulvovaginal candidiasis, candida vulvovaginitis, candidiasis vulvovaginal, moniliasis vulvovaginal, Candidal vulvovaginitis NOS (disorder), Candidal vulvovaginitis, Monilial vulvovaginitis, Vulvovaginal thrush, Candidal vulvovaginitis (disorder), Vulvovaginal Candidiasis
French Vulvo-vaginite à candida, Vulvovaginite à candida, Candidose vulvovaginale, Candidose de la vulve et du vagin, Candidose vulvo-vaginale, Moniliase vulvo-vaginale, Moniliase vulvovaginale
Swedish Kandidos, vulvovaginal
Czech kandidóza vulvovaginální, Kandidóza vulvy a vagíny, Vulvovaginální kandidóza, Vulvovaginální kandidová infekce, vulvovaginální kandidóza
Finnish Vulvovaginaalinen kandidiaasi
Italian Moniliasi vulvovaginale, Candida vulvovaginale, Candidiasi vulvovaginale, Candidiasi della vulva e della vagina, Candidosi vulvovaginale
German Kandidose der Vulva und der Vagina, vulvovaginale Candidose, Candidose von Vulva und Vagina, vulvovaginale Candida, Kandidose, vulvovaginale, Moniliasis, vulvovaginale
Japanese カンジダ症-外陰腟, 外陰腟モニリア症, カンジダ症-外陰部腟, 外陰膣モニリア症, 外陰部膣カンジダ症, 外陰部腟カンジダ症, モニリア症-外陰腟, 外陰腟真菌症, 外陰腟カンジダ症, 腟外陰カンジダ症, ガイインブチツカンジダショウ, ガイインブチツカンジダ, 外陰部腟カンジダ
Spanish Cándida vulvovaginal, Candidiasis de vulva y vagina, Candidiasis vulvovaginal, vulvovaginitis candidiásica, SAI (trastorno), vulvovaginitis candidiásica, SAI, vulvovaginitis monilial, vulvovaginitis por Candida (trastorno), vulvovaginitis por Candida, Candidiasis Vulvovaginal, Moniliasis Vulvovaginal
Dutch vulvovaginale candidiasis, candidiasis van vulva en vagina, vulvovaginale candida, Candidiasis van vulva en vagina, Candidiasis, vulvovaginale, Moniliasis, vulvovaginale, Vulvovaginale candidiasis
Portuguese Candidíase da vulva e vagina, Candida vulvovaginal, Candidíase vulvovaginal, Vaginite por Monília, Candidíase Vulvovaginal, Monilíase Vulvovaginal
Korean 외음 및 질의 칸디다증
Polish Kandydoza pochwy i sromu
Hungarian Vulvovaginalis candidiasis, vulvovaginalis candida, vulva és vagina candidiasis
Norwegian Vulvovaginal candidainfeksjon, Vulvovaginal candidiasis, Vulvovaginal kandidose, Vulvovaginal moniliasis, Candidavulvovaginitt, Vulvovaginal candidose, Vulvovaginal moniliase