One of the most common causes of yeast infections in the vulvovaginal area is Candida albicans (Holland et al, 2003; Sobel et al, 2013). During their childbearing years, 75% of women will experience at least one episode of vulvovaginal candidiasis (Hurley and De Louvois, 1979) and about 5–8% of these women will have recurrent vulvovaginal candidiasis (RVVC) at least once during their lives (Hurley and De Louvois, 1979; Sobel, 2007). However, 10–20% of women may be colonised with Candida but be asymptomatic (British Association for Sexual Health and HIV (BASHH), 2007). Vulvovaginal candidiasis can be found in 40% of healthy pregnant women (Hay and Czeizel, 2007). With these high numbers it is important to consider the impact that candidiasis can have on the pregnant mother or baby.
Recurrent vulvovaginal candidiasis
Sobel (2007) defines RVVC as: ‘four or more episodes of VVC in 12 months’ (Sobel, 2007: 1961). Hong et al (2014) suggest that it can be diagnosed using the criteria of chronic non-specific and non-erosive vulvovaginitis. Thus women need to have at least five of the following signs and symptoms:
Hong et al (2014) suggest oral medication such as clotrimazole should be the first-line of treatment as it is the most effective form.
Risk factors
Predisposing factors for RVVC are thought to be familial susceptibility, pregnancy, the use of systemic antibiotics, diabetes mellitus, and promiscuous sexual behaviour (Rhoads et al, 1987; Cotch et al, 1998; Wilton et al, 2003; Babula et al, 2005). These risk factors are thought to be related to a depressed immune system such as with a chronic infection, like HIV, or taking immunosuppressants, such as corticosteroids. Women with diabetes are also immunosuppressed so they are more likely to catch infection. In a recent study by Sharma and Solanki (2014) it was shown that Candida also binds more effectively to the vaginal epithelial cells in patients with diabetes.
Another risk factor for VVC and RVVC is the use of oral contraceptives or hormone replacement therapy: the incidence of candidiasis is rare in premenarchal girls and post-menopausal women (Sobel et al, 2013). Pregnant women are at higher risk in the third trimester of their pregnancy due to the high levels of female reproductive hormones, which increase the glycogen content of the vagina. This high glycogen content provides a rich carbon source for Candida growth and reproduction (Sobel et al, 2013; Sharma and Solanki, 2014). Oestrogens also increase the vaginal epithelial cells affinity for Candida adherence.
Clinical signs and symptoms
The symptoms of candidiasis can be very uncomfortable. The cause, however, can only be ascertained by swabbing the area. The signs and symptoms of thrush are the same whatever the type of fungal infection (BASHH, 2007).
The symptoms are:
The signs are:
Candida colonisation is not thought to be associated with congenital abnormalities, low birth weight or preterm delivery (Cotch et al, 1998; Young and Jewel, 2001). However, Hay and Czeizel (2007) have suggested a link as eradication of candidiasis during pregnancy is thought to reduce the risk of preterm delivery. Therefore irradication of vaginal candidiasis should be considered in women with a history of previous preterm labour (Roberts et al, 2014). Although Candida is associated with the presence of Trichomonas vaginalis, Group B Streptococcus, and aerobic Lactobacillus, Lactobacillus are needed to inhibit the growth of bacteria and restore an equilibrium in the normal vaginal flora (Cotch et al, 1998; Hillier et al, 1993).
Management of candidiasis in non-pregnant women
In non-pregnant women, mild vaginal thrush can be treated with a short course of antifungals such as fluconazole 100 mg weekly x 6 months and clotrimazole pessary 500 mg weekly x 6 months. Symptoms can settle after 3 days and treatment is effective in 80% of cases (Electronic Medicines Compendium (EMC), 2013). The treatment regimens for RVVC are shown in Table 1.
| Fluconazole 100 mg weekly × 6 months |
| Clotrimazole pessary 500 mg weekly × 6 months |
| Itraconazole 400 mg monthly × 6 months |
| Ketoconazole 100 mg daily × 6 months |
Adapted from: BASHH (2007)
Management of candidiasis in pregnant or breastfeeding women
Women with recurrent candidiasis are recommended to be treated with topical azoles if they are pregnant (Watson et al, 2001; Young and Jewell, 2001; Joint Formulary Comittee, 2014), oral antifungal treatment should be avoided during preganancy (Joint Formulary Comittee, 2014). The current guidelines recommend that vulvovaginal candidiasis is treated with intravaginal clotrimazole or miconazole for at least 7 days (National Institute for Health and Care Excellence (NICE), 2012; Joint Formulary Committee, 2014). If the woman has symptoms in the vulval area she can be treated slightly differently with topical clotrimazole cream in addition to intravaginal clotrimazole or miconazole (NICE, 2012). Intravaginal miconazole can also be applied directly to the vulval area. If the woman needs both, then she can be prescribed clotrimazole as a combination pack containing a 10% vaginal cream and a 2% topical cream or a combination pack containing a 500 mg vaginal pessary and a 2% topical cream. These are available as branded or generic formulae. Clotrimazole and miconazole are considered safe to use in pregnant women as there is no evidence of an increased risk of spontaneous abortions or congenital abnormalities with clotrimazole (EMC, 2013). Miconazole has shown no fetotoxic effect in animal studies (EMC, 2013). Other topical imidazoles are not recommended (NICE, 2012).
Pregnant women are not prescribed oral treatment during pregnancy because it may affect the baby (NICE, 2012). This includes the most common antifungals, such as fluconazole and itraconazole. However, in one study of 171 523 pregnancies, of which 1079 filled a fluconazole (≤150 mg daily) prescription during the first trimester, there was no evidence of an increased risk of congenital malformations or miscarriage after exposure to short-course treatment with fluconazole in early pregnancy (Nørgaard et al, 2008). A much smaller UK-based study also reported no incidents of congenital abnormality with oral fluconazole, (Inman et al, 1994). There was however, a small number of cases that reported congenital malformations similar to the Antley-Bixler syndrome in infants where mothers received high dose fluconazole (≥400 mg daily) for prolonged periods during the first trimester of pregnancy, (Pursley et al, 1996).
Table 2 outlines the guidance around prescribing of oral fluconazole in pregnancy.
| Topical imidazoles-clotrimazole: First-line for the treatment of Candida. These need to be used for at least 7 days. |
| If topical treatment is ineffective, low dose oral fluconazole (150 mg single dose) may be considered as second-line treatment. |
| Inadvertent exposure to low dose fluconazole in pregnancy does not constitute a need to seek termination of the pregnancy. The mother should be reassured that the risk to the baby is minimal. |
| If high dose fluconazole treatment is given to a woman of childbearing age then she should be counselled on the use of adequate contraception because of the potential for birth defects. |
If non-pregnant women need to be treated with a long-term regimen (an initial period of treatment followed by a maintenance regime for 6 months) (BASSH, 2007), it is important that they are educated in the importance of concordance as there can be a 50% chance of relapse after treatment (BASSH, 2007). There is therefore a need for partnership planning with the women and the clinician in order to support patient adherence.
Thrush in the breast and nipple while breastfeeding
The diagnosis of infections of Candida on the breast is difficult as it generally relies on the subjective signs and symptoms of the mother. Causative factors are; the presence of vaginal Candida at delivery, nipple damage, the use of maternal antibiotic at delivery, poor sterilisation techniques, use of dummies, bottles and breast pumps, postnatal women and a pregnancy duration more than 40 weeks (Amir, 1991).
Candida is often considered as one of the causes of nipple pain and therefore a cause in early stoppage of breastfeeding or complications of breastfeeding (Breastfeeding Network, 2009). The Baby Friendly Initiative (2014) suggests that there is a tendency to over-diagnose thrush. Midwives therefore need to observe all breastfeeding mothers to ensure that the nipple pain they are experiencing is due to other causes such as ineffective attachment.
Medical treatment is that of miconazole cream which can be applied to the nipple after each feed (NICE, 2012). The oral gel version can be applied to the newborn's palate. There is also a nystatin suspension in a drop form as an alternative.
Pessaries
The most common medication used in the pessary form are clotrimazole, econazole and miconazole. These pessaries are not absorbed into the body but they can be difficult to use, cause localised discomfort and stain underwear. There is also some concern about using them with an applicator during pregnancy (NICE, 2012). Women are therefore advised to be careful when using an applicator during pregnancy and to avoid physical damage to the cervix. It may be advisable to insert the pessary by hand.
Treatment failure in pregnancy
If treatment has not been successful and the woman still has symptoms 7–14 days later, further investigation is required (NICE, 2012). Consider the following:
Postpartum/non-breastfeeding thrush
If a woman has RVVC in the post-partum period and is not breastfeeding, then they can be started on oral anti-thrush treatment. RVVC is commonly treated with oral fluconazole 150 mg weekly for 6 months (Rosa at al, 2013). This cannot be recommended for pregnant women. In non-pregnant women who are breastfeeding, the options are also restricted. Fluconizole is not licensed for breastfeeding women, but has found to be effective in treating RVVC (Brent, 2001). There is a lack of evidence about the amount of fluconazole excreted in the breast milk and the risk of its impact on preterm infants. Brent (2001) would suggest that there is a lack of consensus of opinion and that fluconazole is commonly used in mothers who are breastfeeding their infants. Although not licensed, it is prescribed with caution and is common practice and approved by BFI. Generally the common use of fluconazole without reported adverse effects in breast-fed infants does suggest that oral fluconazole is therefore safe in mothers breastfeeding full term infants.
Complementary therapies
There are a wide range of complementary therapies for the treatment of Candida infections, including inserting plain bio-live yoghurt on a tampon into the vagina. Yoghurt ingested orally can also act as a preventative measure for thrush due to colonisation with Lactobacillus. The research is unclear as to how effective the use of probiotics such as Lactobacillus are but they are widely used by patients and are considered unlikely to do harm (Watson et al, 2012). Daily ingestion of yoghurt containing lactobacillus is said to decrease the colonisation of the vaginal tract by candida (Hilton et al, 1992).
Consuming a low-sugar diet may also prevent candidiasis. There is a need for further research in this area but the initial evidence links Candida to high dietary sugars (Jin et al, 2004). Although one may wonder if it is linked to improving type 2 diabetes or impaired glucose fasting (Donders et al, 2002). Other preventive measures include educating women to wipe from front to back as re-infection can occur from the bowel (Young and Jewell, 2001). There is certainly less conclusive evidence about this advice, but the use of cotton underwear, avoiding highly perfumed toiletries and tight clothing is recommended (NICE, 2012). Tea tree oil should not be used as there is a lack of evidence about its effectiveness and it can cause sensitivity (BASH, 2007; Crawford et al, 2004). The guidelines from BASH are currently being updated and they suggest that tea tree oil is not used.
Partners
The current advice for sexual partners is that they should be treated only if they are symptomatic (NICE, 2012). The male partner of a woman with vulvovaginal candidiasis may present with balanitis, which can easily be treated with a topical or oral antifungal.
Conclusion
The accurate diagnosis and management of RVVC may have a positive impact on the quality of life of women. Although common in pregnancy, candidasis should not be ignored as it can be painful and distressing. The guidelines are clear and concise in regards to medication and pregnant women can be reassured that it can be treated.