Q: I keep getting yeast infections. Is it okay to self-treat with over-the-counter products?
A: You're in good company, since 75 percent of all women have a diagnosis of vaginal yeast infections (vaginal candidiasis) at some point in their lives. Only five percent have the recurrent form of this disorder, (defined by the experts as four or more documented episodes in a year).
My first concern is whether you are indeed suffering from yeast infections. Often we read the packaging or see consumer Ads put out by the over-the-counter products that treat yeast describing “what it's like to hurt down there” and are persuaded to use these remedies when the culprit isn't yeast at all. The most common cause of vaginal irritation and discharge is actually nonspecific bacterial vaginosis, which affects 75 percent of women and is much more common than yeast (which has been found to be the source of vaginitis only 15 to 30 percent of the time).
So, before I explain what yeast does (other than help dough rise) and how a diagnosis of abnormal vaginal yeast infection is made, I want to say a few words about bacterial causes of vaginal pain and discharge. In order to do that I have to discuss things that may seem gross, but will help you understand what's thriving in our vaginal tract and what regulates our normal flora. The most important bacteria in this domain are lactobacilli, which play an important function in maintaining the normal acidic vaginal pH of 3.8 to 4.5. Lactobacilli produce hydrogen peroxide, which inhibits the growth of bacteria and, by the way, can destroy HIV in cell cultures.
When bacterial vaginosis occurs (and this accounts for up to 50 percent of the cases of acute vaginitis) the vaginal flora changes so that lactobacilli dominance gives way to bacteria that don’t like oxygen. An examination by a physician would also show that the vaginal pH is higher than usual (above 4.5) and a microscopic analysis of the fluid would reveal multiple bacterial cells adhering to cells that normally live in the vaginal walls (clue cells). The symptoms of this condition include a watery, irritating, fishy-smelling discharge. There is a definite sexual correlation to this “non-oxygen liking bacteria takeover” down there. Bacterial vaginosis is more likely to occur in women who have more than one sexual partner, have changed sexual partners in the previous 30 days, have had a female sexual partner, and those who douche monthly (this screws up the vagina's pH and flora and shouldn't be part of your hygiene routine). Bacterial vaginosis is a form of abnormal vaginal environment that can lead to other complications including miscarriage, preterm labor, serious infection after surgery and pelvic inflammatory disease. It should be treated with either oral antibiotics that go after non oxygen liking bacteria (Flagyl) or vaginal creams that contain the same antibiotic (Metronidazole) or the antibiotic Clindamycin.
Now, let's get to your concern about repetitive vaginal infections. The first thing to do is make sure that your infections are indeed due to yeast. At some point make that appointment with your gynecologist or healthcare provider so she or he can evaluate the discharge and irritation and decide if it is yeast. If you're developing fissures (little cracks in the skin) it's likely yeast. If the discharge is white and cottage cheese-like, there's a good chance that it's yeast, but not necessarily. Finally, if yeast is the cause, the pH of your vagina won't change and a microscopic analysis of the smear will show typical yeast forms (hyphae).
Once this has been documented, there are various therapies you can try. If the infections keep recurring, though, you and your doctor need to look for an underlying cause. These can include:
- Recurrent use of broad-spectrum antibiotics, such as tetracycline, ampicillin, and cephaposporins. (They all tend to eliminate the protective lactobacilli and allow yeast to emerge as the microscopic victor).
- An altered local immune response that seems to predispose to these infections.
- Use of spermicides
- Increased glycogen production (a form of sugar) by the cells lining the vagina during the second half of your menstrual cycle (luteal phase). This can “feed” yeast.
- Anything that changes the normal vaginal flora, allowing yeast to grow…. including certain perfumed soaps, bubble baths and even highly chlorinated pools and Jacuzzis.
- High dose, but not low-dose oral contraception
- A less common form of yeast called Candida glabrata, found in up to 15 percent of women with recurring infections. This form doesn't respond to the "usual" treatment of yeast vaginitis.
The over-the-counter therapies do work well for one-time or “occasional-time” infections provided they are yeast. Again, I want to point out that several studies have shown that up to 50 percent of women who thought they had yeast vaginitis actually had something else. In these cases the over-the-counter medications obviously won't work.
Here's a list of treatments out there, from the cheapest to the most expensive, according to the CDC 2006 Guidelines for Treatment of Vaginitis:
- Mycelex-7 cream: Use it for seven days.
- Gyne-Lotrimin: Take two vaginal tablets for three days or one tablet for seven days.
- Monistat-1 vaginal ovule: Take it for one day.
- Monistat 1-Day: Use ointment for one day.
- Terazol 3 : Use vaginal cream for three days
- Monistat 7: Use vaginal suppository for seven days
- Monistat –3: Use suppository for three days
- Terazol –7: Use cream for seven days:
- Gynazole-1: Use sustained release cream for one day
- Nystatin vaginal tablets: Use one a day for 14 days
- The oral pill Diflucan: One 150mg dose pill
Some of these treatments require a prescription, while others are obtained over-the-counter, but they all seem to have effective responses when given for the right kind of infection. If, however, your yeast infection is recurrent and severe, you and your doctor might consider a single dose of Diflucan, followed by another pill 72 hours later, or you can take a 10-day course daily with a weekly suppressive dose (of 150 mg) for the following six months.
If your infections don't respond to these treatments, and if culture shows that they are due to a type of yeast that is not c.albicans, talk to your doctor about a longer treatment with a Terazole type product followed by a trial of vaginal boric acid capsules (these are compounded at special pharmacies) for 14 days , and subsequent use of one to two capsules a week for the next six months to prevent recurrence.
Dr. Reichman’s Bottom Line: This is probably much more information than you ever wanted to know about pain and discharge “down there,” but since it's so common and there are so many treatment choices, I thought you should know. The vaginitis that is correctly diagnosed will be the vaginitis that is cured…
Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.