recurrent vaginal yeast infection


Vulvovaginal candidiasis (VVK) is caused by a fungus called Candida albicans. Candida is colonized in the normal vaginal flora in 25% of women. Candida albicans is responsible for 89% to 92% of cases with vulvovaginal candidiasis. Other candida species are responsible for the occurrence of this disease, to a lesser extent. It is an opportunistic fungal infection that affects approximately 75% of women of reproductive age. Recurrent vulvovaginal candidiasis (chronic vulva vaginal candidiasis: CVVK) affects 5% to 8% of premenopausal women. Four or more recurrences of this disease are required each year to be able to diagnose CVVK.


In the clinic, edema in the vulva, edema in the vagina, and cheesy milk curd-like discharge are observed. The majority of women with CVVC have itching in the vulva, which is severe and very disturbing. The severity of this itching and infection is not compatible with the number of fungal organisms. Irritation in the vagina, burning and tingling occurs during urination, this complaint becomes more prominent especially if there are abrasions due to itching in the vulva. An important metabolic disease such as diabetes, which lowers body resistance, should be investigated in patients with very common redness (erythema) and edema on the vulva skin. Even if VVK does not have a bad odor, patients may also complain of bad odor if different microbes grow together with the fungal infection.


Vaginal yeast infection occurs as a result of the proliferation of fungal cells present in the normal vaginal flora of individuals for various reasons. Although it is generally known as a sexually transmitted disease, sexual intercourse is not necessary for its emergence, it can be seen even in virgins and little girls. Fungus-candida that reproduces between beach sands, especially in summer, can also cause infection.


Although KVVK is due to many causes, the cause cannot be determined in approximately 50% of the cases. Among the risk factors that cause CVVK, use of antibiotics, birth control pills, frequent sexual intercourse, use of commercial vulvovaginal solutions, inadequate treatment of vaginal candidiasis, hormonal drugs, pregnancy, diseases that affect the immune system such as DM and HIV infection can be counted. Hormonal fluctuations and using antibiotics are the factors that cause VVK and CVVK the most. Hormonal fluctuations, especially g covers midwifery, the luteal phase of menstruation, using oral contraceptives, and hormone replacement therapy. Unidentified congenital or acquired immune deficiency increases the possibility of CVD as well as VVC. In addition, nylon underwear, which disrupts the ventilation of the genital area and causes it to remain wet all the time, being overweight (obesity) paves the way for fungal infection.


In many studies, although almost half of the patients with CVV are symptomatic, candida culture gives negative results in the evaluation. In this case, especially in patients with CVV, the diagnosis should be confirmed by seeing typical fungal forms with 10% potassium hydroxide or saline microscopic examination. Even if candida spores or hyphae are not found in the examination with potassium hydroxide, this does not mean that there is no infection and the patient can be treated depending on clinical findings and suspicion. If a vaginal culture is taken for candida research, the result will be available within 24-72 hours. It may be wrong for patients to diagnose CVV on their own, and vulvar irritation and contact dermatitis may develop as a result of incorrect treatment.


Clinically symptomatic VVK and CVV cases should be treated, including pregnant women. The underlying cause should be investigated and eliminated, especially in frequently recurring CVV cases.

In locally applied treatments (with imidazole and azole groups), at least 80% of VVK cases respond to treatment. However, treatment success is low in KVVK cases. Some women with CVV are advised to douche with natrium tetraborate (Borax). In some women, tampons with Tea Tree Oil can be used, but this treatment can also cause frequent allergic reactions. If fungi found in the oral cavity, penis, or seminal fluid of male partners are treated, women with CVV are less likely to have a recurrence of the fungal infection.

Implementation of impractical, unsafe, unproven treatment options also causes the spread of the disease. To date, no standard treatment for this disease has been found. The main discussion on this issue; It is a question of whether it is more appropriate to treat each time a CVVK diagnosis is made, to use drugs continuously or to use drugs periodically for prophylaxis. For the treatment of each attack, oral flucanazole and azoles used locally are a safe and practical option. Oral ketoconazole, local miconazole and oral itraconazole can be used for prophylaxis.
The most effective treatment strategy in CVVK is the chronic suppression program. In practice, oral or vaginal azole antifungal agents are continued for 14 days. The most appropriate treatment in the suppression phase is fluconazole 150 mg administered orally once a week. For the suppression of CVVK, oral flucanazol 150 mg once a week, 6 months of treatment, the success rate is close to 90%. Alternative treatments are ketoconazole 100 mg given orally once a day or itraconazole 100 mg given orally every other day, as an alternative, topical (intravaginal) azole preparations can be applied once a day. Success rates are greater than 90% in the suppression regimen.

Candida glabrata, the other non-albicans candida species, is rarely seen in women with CVV. Candida glabrata is more common in non-chronic acute infections. The main problem is that Candida glabrata has varying degrees of resistance to azole antifungal agents. Topical administration of 600 mg Boric acid daily for two weeks can control infection acutely, but due to the relative resistance of Candida glabrata to azole antifugal agents, effective maintenance regimens cannot be used.
If the male partner is uncircumcised or has symptoms of fungal balanitis (inflammation of the glans under the foreskin), it should be treated. In KVVK cases, the treatment of the sexual partner should be treated simultaneously with oral fungicides.


The incidence of VVC in pregnant women is 2-20 times higher than in non-pregnant women. The changing hormonal environment during pregnancy causes the infection to recur and makes the treatment more difficult. Most of the locally used antifungal drugs are more effective if given for longer than 1-2 weeks. However, single-dose treatment with clorimazole may also be effective in pregnant women. Vaginal antifungal therapy is safe during pregnancy, since systemic absorption is very low in vaginal antifungal therapy. Only topical treatment is recommended during pregnancy. Oral antifungal drugs are not recommended during pregnancy. Oral triazole group drugs such as ketoconazole are not used in lactating women because they are excreted in milk.

Kiss. Dr. Kutlugul Yuksel

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