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Candida Vulvovaginitis
Aka: Candida Vulvovaginitis, Candida Vulvo-vaginitis, Vaginal Candidiasis, Vulvovaginal Candidiasis, Vulvovaginal Moniliasis, Yeast Vaginitis
- See also
- Vaginitis
- Epidemiology
- Candida Vulvovaginitis accounts for 45% of Vaginitis
- Candida is cultured in 20-50% asymptomatic women
- Vaginitis often self diagnosed incorrectly
- Etiology
- Acute: Candida albicans (90%)
- Normal commensal organism in vagina
- Infection when Corynebacterium suppressed
- Recurrent Vulvovaginal Candidiasis (4 or more episodes in a year)
- Candida glabrata (increasing Incidence, now 15%)
- Candida tropicalis
- Candida parapsilosis
- Candida krusei (responds to Topical Antifungals, but not to Fluconazole)
- Saccharomyces cerevisiae
- Risk Factors
- Immunosuppression
- Diabetes Mellitus (esp. Uncontrolled)
- Depressed cell mediated Immunity (e.g. HIV or AIDS)
- Medications
- Corticosteroids
- Immunosuppressant Medications
- Broad spectrum antibiotics
- Oral Contraceptives
- Increases frequency of Candida carrier state
- Does not increase symptomatic Vulvovaginitis
- Heat and moisture retaining clothing (e.g. nylon)
- Pregnancy (and other hyperestrogenic states)
- Premenstrual phase of the Menstrual Cycle
- Obesity
- Symptoms
- Asymptomatic in 20-50% of women
- Intense vaginal or Vulvar Pruritus (50% of cases)
- Vulvar Burning, soreness, or irritation
- Thick white curd-like or "cottage cheese" discharge
- No odor
- Dyspareunia
- Dysuria (33% of cases)
- Signs
- Adherent white cottage-cheese discharge in vagina
- Sensitivity: 50%
- Specificity: 90%
- Vulvar erythema and edema (24% of cases)
- Labs: Initial
- KOH Preparation (10%)
- Test Sensitivity: 50%
- Pseudohyphae or budding yeast forms

- Vaginal pH <4.5 (Normal acidity)
- Absent Amine odor
- White Blood Cells not increased
- Wet-Prep is not sensitive or specific for yeast
- Bornstein (2001) Infect Dis Obstet Gynecol 9:105-11 [PubMed]
- Candida on Pap Smear
- Specific but very low Test Sensitivity
- Labs: Complicated cases
- Indications: Complicated Vulvovaginal Candidiasis
- Recurrent candida Vaginitis (4 or more episodes in a year) OR
- Severe candida infections OR
- Immunocompromised patients (AIDS, poorly controlled Diabetes Mellitus)
- Fungal Culture positive
- Fungal Culture is rarely performed in typical cases (fungal PCR preferred)
- Fungal Culture may be very helpful in complicated cases
- Confirm asymptomatic carrier of vaginal Candida
- Identify cause of recurrent Vaginitis
- DNA probe or PCR for candida
- Consider in cases refractory to standard therapy
- Differential Diagnosis (Consider for refractory cases)
- Other Vaginitis cause
- Bacterial Vaginosis
- TrichomonasVaginitis
- Infectious Cervicitis (Sexually Transmitted Disease)
- Allergic Vaginitis or Vulvitis
- Vulvodynia
- Herpes Simplex Virus
- HSV presents with unilateral painful lesions
- Contrast with bilateral, symmetric involvement in Candida Vulvovaginitis
- Management: OTC Local First-Line Agents
- Precautions
- In pregnancy, limit to topical azole preparations (Miconazole, Clotrimazole) used for 7 days (lower concentrations)
- Miconazole (Monistat)
- Miconazole (Monistat-7) 2% cream PV qhs for 7 days
- Miconazole (Monistat-3) 4% cream, 5 g PV qhs for 3 days
- Miconazole Vag tabs 100mg PV qhs for 7 days
- Miconazole (Monistat-3) 200mg PV qhs for 3 days
- Miconazole 1200 mg vaginal tab PV qhs, 1 dose
- Clotrimazole (Gyn-Lotrimin, Mycelex G)
- Clotrimazole 1% cream qhs for 7 days
- Clotrimazole 2% cream qhs for 3 days
- Clotrimazole 200 mg vaginal tab PV qhs for 3 days
- Clotrimazole 100 mg vaginal tab PV qhs for 7 days
- Clotrimazole 500 mg vaginal tab PV qhs, 1 dose
- Terconazole (Newer, binds better to Candida)
- Vagistat-1 6.5% ointment, 5 g intravaginally once
- Highly effective and less irritating than creams
- Management: Prescription Local First-Line Agents
- Butoconazole (Femstat)
- Mycelex-3 5g of 2% Cream PV QHS for 3 days
- Gynezole-1 (sustained release, bioadhesive) 5 g of 2% cream once intravaginally
- Terconazole (Newer, binds better to Candida)
- Terazol 80 mg vaginal suppository PV for 3 days
- Terazol-3 (0.8%) 5 g vaginal cream for 3 days
- Terazol-7 (0.4%) 5 g vaginal cream qhs for 7 days
- Nystatin
- Nystatin vaginal tablet (100,000 unit) PV daily for 14 days
- Nystatin ointment (100,000 units/g)
- Ointments are less irritating than creams
- Management: Oral Agents
- Fluconazole 150 mg PO for 1 dose
- As effective as Clotrimazole PV
- Do not use in pregnancy
- Evidence of Miscarriage risk, with even 1-2 doses
- Mølgaard-Nielsen (2016) JAMA 315(1):58-67 +PMID:26746458 [PubMed]
- Consider repeat scheduled treatment for persistent symptoms
- Consider prescribing Fluconazole 150 mg every 3 days for up to 3 doses for persistent Vaginitis symptoms
- Symptom improvement delayed for 24 hours with Fluconazole
- Consider concurrently treating with Nystatin ointment (100,000 units) for the first several days (least irritating)
- References
- (1994) Med Lett Drugs Ther 36(631): 1-2 [PubMed]
- Management: Recurrent or resistant Treatment
- Precautions
- Avoid treating asymptomatic carriers (may be normal flora in some patients)
- Consider risk factors above
- Any of above intravaginal meds for 14-21 days
- Consider maintenance after initial daily regimen
- Maintenance: Repeat application once weekly
- Consider using monthly at time of Menses
- Consider Terconazole (see above)
- More effective against other candida species
- Fluconazole (Diflucan)
- See below for maintenance protocol
- Less effective for non-albicans Candida
- Dose 1: 150 mg orally
- Dose 2: 150 mg PO at 72 hours after first dose
- Consider a 3rd dose at 72 hours after second
- Sobel (2001) Am J Obstet Gynecol 185:363-9 [PubMed]
- Other options (many with increased toxicity and risk)
- Ketoconazole (Nizoral) 200mg PO bid for 5-14 days
- Itraconazole (Sporanox) 200 mg PO qd for 3 days
- Gentian Violet vaginal staining 1-2x (Office charge)
- Boric Acid 600 mg vaginal tab bid for 14 days
- Use is controversial, but may be considered in refractory non-albicans candidal infection
- Sobel (2003) Am J Obstet Gynecol 189(5): 1297-1300 [PubMed]
- Flucytosine (Ancobon) cream applied to affected area
- Management: Prophylaxis (more recent protocol)
- Indication
- Four or mor yeast infections per year
- Initial treatment
- Fluconazole (Diflucan) 150 mg PO q3 days for 3 doses
- Maintenance
- Fluconazole (Diflucan) 150 mg PO each week
- Monitor liver enzymes (consider q1-2 months)
- Efficacy
- Suppression while on treatment: 90%
- Following treatment: Infection recurs in 60%
- References
- Sobel (2004) N Engl J Med 351:876-83 [PubMed]
- Management: Prophylaxis (old protocol)
- Protocol for 6 month maintenance regimen
- Start with 2 week recurrent treatment option above
- Follow treatment with prophylaxis option below
- Fungal Culture and exam timing
- Baseline
- Two weeks (after treatment regimen above)
- Three months
- Six months (when stopping prophylaxis)
- Medications
- Clotrimazole 500 mg vaginal tab weekly to montly
- Fluconazole 150 mg orally once weekly to monthly
- Miconazole 100 mg vaginal tab qhs twice weekly
- Avoid oral Ketoconazole due to hepatotoxicity
- Prevention
- Control predisposing condition (e.g. Diabetes Mellitus)
- Reduce predisposing medications (e.g. Corticosteroid)
- Avoid moisture-retaining products near vagina
- Nylon underwear
- Panty-liners
- Vaginal Lubricants or Spermicides
- Lactobacillus (Probiotic) is not effective
- Does not prevent post-antibiotic Vaginitis
- Pirotta (2004) BMJ 329:548-51 [PubMed]
- References
- Desai (1996) Am Fam Physician 54(4):1337-40 [PubMed]
- Hainer (2011) Am Fam Physician 83(7): 807-15 [PubMed]
- Nyirjesy (2001) Am Fam Physician 63(4):697-702 [PubMed]
- Paladine (2018) Am Fam Physician 97(5): 321-9 [PubMed]
- Sobel (1998) Am J Obstet Gynecol 178:203-11 [PubMed]
- Tobin (1995) Am Fam Physician 51(7):1715-20 [PubMed]