Vaginal thrush is a yeast infection caused most commonly by the fungus Candida albicans. Most of the time, bacteria and fungus live naturally in and around the vagina and do not cause any symptoms. This is because the immune system, and the “good” vaginal bacteria all women have, are usually able to stop overgrowth of the Candida fungus.
How does your body protect you from thrush?
The majority of the ‘friendly’ bacteria found in the vagina are called lactobacilli, and they play a really important role in protecting the vagina from unwanted infections!
- They produce lactic acid that makes the inside of the vagina slightly acidic to prevent other bacteria from growing there.
- They also act as a protective barrier so other bad bacteria cant grow on the lining of the vagina instead. When levels of lactobacilli are lower, this allows other bacteria to develop, which is thought to be the reason conditions such as Thrush and Bacterial Vaginosis thrive.
When conditions favour fungi growth, their numbers can multiply quickly and spread throughout the vagina. When this happens, the vagina can become inflamed (vaginitis), causing the typical thrush symptoms of soreness, itching and irritation.
What is thrush?
Thrush is very common: around 75% of women develop vaginal thrush at least once in their lifetime. Simple thrush infections are often straightforward to treat, and most women get relief from their symptoms shortly after starting medication.
However, for a small number of women, thrush infections keep coming back (recurrent thrush) even with appropriate treatment. Repeated spells of thrush can have a significantly negative impact on your quality of life and it can be hard to know where to begin to tackle these infections.
This post will explore the possible causes for recurrent thrush, as well as the available treatment options and tips for preventing repeated infections.
What is recurrent thrush?
Recurrent thrush is defined as four or more thrush infections within a year period. Around 5 out of every 100 women who develop a first episode of vaginal thrush ultimately struggle with recurrent thrush.
Sufferers may find that they repeatedly get new thrush infections following treatment or that they have persistent symptoms that wax and wane in severity despite completing courses of treatment.
Symptoms of recurrent thrush:
The symptoms of recurrent thrush are similar to those you would expect with a simple thrush infection. Some women find that their symptoms disappear completely between infections, while others struggle with continual symptoms that can improve or worsen at different times.
Common symptoms include:
⭐ Itchiness of the skin outside the vagina (vulva) and/or inside the vagina
⭐ Soreness/irritation/mild redness of the vulva
⭐ Creamy white, thick and non-smelling vaginal discharge (often referred to as like “cottage cheese”)
⭐ Pain on passing urine
⭐ Pain on sexual intercourse
Signs that you might have a more severe thrush infection include:
⭐ Cracked or damaged skin around the vulva
⭐ Significant redness around the vulva and/or vagina, that might extend to the labia majora and/or perineum
⭐ Swelling of the vulva and/or labia majora
It is important to remember that thrush is not the only cause of vulval itching, soreness or vaginal discharge. The presence of one or more of the following symptoms suggest that you might have a condition other than thrush:
⭐ Vaginal discharge that is smelly or coloured
⭐ Bleeding between periods or post-intercourse
⭐ Rash and/or blisters on the skin around the vulva
⭐ Tummy (abdominal) pain
⭐ Needing to pass urine more often than normal
⭐ Feel unwell in yourself (e.g. fever) in addition to the vaginal and/or vulval symptoms
What causes vaginal thrush?
The vagina has natural defenses, including mucus and healthy bacteria, that protect it against the overgrowth of fungus. When these defenses are disturbed or altered, the fungus can invade the vagina, causing a thrush infection.
Thrush is not considered to be a sexually transmitted infection (STI), but it can sometimes be triggered by sex or passed between partners through intercourse. Importantly, vaginal thrush is not the result of poor hygiene.
There is often no single cause for thrush, but there are certain factors which can disrupt the vagina’s natural defenses and make you more likely to develop a thrush infection (and/or have recurrent episodes of thrush).
These factors include:
⭐ Taking antibiotics
⭐ Oestrogen hormone exposure (e.g. during pregnancy, women in their reproductive years and/or use of hormone replacement therapy)
⭐ Having a weakened immune system (e.g. caused by conditions such as HIV or medications such as chemotherapy or steroids)
⭐ Going through or having gone through the menopause
⭐ Having poorly controlled diabetes
⭐ Damaged and/or irritated skin around the vulva
⭐ Certain behavioural or lifestyle choices (e.g. wearing non-breathable clothing, vaginal douching, frequently using panty liners and/or taking hot baths, etc.)
There is some evidence that the use of the combined oral contraceptive pill might predispose to thrush infections. However, the evidence on this is not yet conclusive.
Although the factors above might make you more prone to developing thrush, some women develop a thrush infection (or have recurrent episodes of thrush) without any obvious triggers. Experiencing one, or more of the factors above, does not mean that you will definitely suffer with recurrent thrush.
Why do I have recurrent thrush?
In most cases, the reason why some women suffer with recurrent bouts of thrush is not clear. Unfortunately, it appears that some women are simply more prone to developing thrush infections than others.
However, there are some factors that might be contributing to your recurrent thrush, including:
- Treatment for a previous episode of thrush did not fully clear the infection (this can be because the treatment course was not strong or long enough or because it was not taken properly). It is really important to always complete the full course of treatment.
- Having thrush that is caused by a strain of the Candida fungus that is resistant to the standard treatment (up to 2 in 10 women who develop recurrent thrush are infected with a fungus strain called Candida glabrata rather than the more common Candida albicans).
- Becoming re-infected with thrush through sexual intercourse (e.g. passing the infection back and forth between partners).
- Being continually affected by a condition or situation that increases your risk of developing thrush (e.g. poorly controlled diabetes, being pregnant or having a weakened immune system).
- Taking part in repeated behaviour that causes vulval irritation, such as vaginal douching, using perfumed soaps and wearing tight-fitting clothing, etc.
- It is possible that you do not, in fact, have recurrent thrush but actually there is another cause for your symptoms such as skin conditions or other infections.
When should I see a doctor?
The cause of recurrent thrush is often unclear and complex, so it is always advisable to see a doctor (e.g. your GP) if you are suffering with repeated episodes of thrush. You are also likely to require treatment that is different, and more long-term, from that which is available over-the-counter. Although thrush is not an STI, most sexual health clinics will also be able to assess, diagnose and treat women struggling with recurrent thrush.
It is important to remember that vulval itching and discharge can be caused by many conditions other than thrush and a healthcare professional is the only person who can safely and adequately diagnose your symptoms.
Even if you have successfully treated yourself for thrush in the past, it is recommended that you always consult a healthcare professional if any of the following applies to you:
- You have any of the symptoms we have listed above as suggesting that you might have a condition other than thrush
- Under 16 or over 60 years of age
- Are pregnant or trying to conceive
- Have diabetes
- Have had a previous STI and/or are concerned that you might have been exposed to an STI (e.g. via unprotected intercourse)
- Have taken an over-the-counter thrush treatment but your symptoms have not resolved
- Have symptoms that are different in any way from those you experienced during a previous episode of thrush (e.g. if you have developed vaginal discharge that smells or ulcers/blisters around your vulva)
- Have previously had a bad reaction to anti-thrush medications
- Have a weakened immune system (e.g. if you are on chemotherapy or long-term steroid medication)
What will happen when I see a doctor?
The aim of your consultation will be to determine if thrush is in fact the cause of your symptoms and to identify any factors that might be pre-disposing you to recurrent thrush.
If you are struggling with recurrent thrush, your doctor might want to examine you and perform some tests. Possible tests you might have include:
- Vaginal swabs to determine if you have a thrush infection and, if so, which Candida fungal species is responsible. Swabs are also used to test for other infections which might be causing your symptoms.
- A pH test to check the acidity level of your vagina, which can be useful in distinguishing between thrush and bacterial vaginosis (another very common cause of unusual vaginal discharge).
- This involves placing a small test strip into the vagina. The colour change of the test strip helps to determine if thrush is the most likely cause of your symptoms.
- Urine tests to check for the presence of an infection, which can sometimes present with symptoms similar to thrush. Your urine might also be screened for sugar, which might indicate diabetes (a condition that can pre-dispose to recurrent thrush).
Treatment for Recurrent Thrush:
Treatment for recurrent thrush is usually a two-stage process.
- First: your doctor will prescribe a regimen of anti-thrush medication to treat your current infection. This stage is known as the “induction course” of treatment, and will usually include either oral anti-fungals (Fluconazole) or intra-vaginal anti-fungals (Clotrimazole pessaries).
It is likely that you will be prescribed a longer course of treatment than that which you have taken for thrush infections in the past.
2. There are usually two options available for the second stage of treatment. You can either:
- Take a course of treatment if and when your symptoms recur. You will be given a prescription for “treatment as required” so that you have anti-thrush medication available to use at the first sign of a recurrent infection.
- Complete a “maintenance course” of treatment. This involves taking anti-thrush medication for around 6 months with the goal of significantly reducing the amount of Candida present.
For both treatment options, you will usually be able to use either oral or intra-vaginal (pessaries) anti-fungal medication. The appropriate treatment option and medication for you will depend on your individual circumstances, personal preferences and previous response to anti-thrush treatments.
If you are struggling with vulval symptoms (e.g. itching, soreness and/or irritation), your doctor can also prescribe a cream for you to use externally. A follow-up appointment is usually arranged at around 6 months, but you can be seen sooner if you have any concerns about symptoms and/or treatment.
How can I stop thrush from coming back?
The fungus that causes thrush is most comfortable in an environment that is warm, moist and airless.
There are a number of general lifestyle and behavioural changes that you can adapt which might help prevent this fungus from being able to thrive. These lifestyle changes may help prevent single episodes of thrush and also reduce the risk of recurrent thrush.
Tips for reducing your risk of thrush include:
Don’t:
❌ Use perfumed soaps and toiletries in and around your genital area. You should also not use feminine wipes, deodorants and/or vaginal douches, which can upset the vagina’s “good” bacteria.
❌ Over-wash your genitals (washing once a day is sufficient).
❌ Wear tight underwear, thongs, stockings and/or trousers, which can cultivate the warm, moist environment that help Candida thrive.
❌ Excessively wax and/or shave your genital region. Over-grooming can lead to small cuts around the vulva, which might make you more prone to irritation and infection.
❌ Use daily panty-liners and sanitary pads and/or tampons with any chemical additives. Instead, consider using a Mooncup or opting for organic, non-bleached, fragrance-free pads and/or tampons. Always follow the instructions on the packet re: when to change/remove sanitary products.
❌ Consume excess sugar and/or alcohol. Remember to keep hydrated and try to maintain as heathy a diet as possible.
❌ Although thrush is not an STI, it is sometimes possible to become infected with thrush through sexual intercourse. It is advisable to wait for symptom resolution before having sex if you or your partner has active thrush. Some of the commonly used intra-vaginal thrush medications can damage condoms; if you are using condoms to protect you from pregnancy and/or STIs, you should always speak with your doctor before starting anti-thrush treatment for advice on the best way to stay safe.
Do
✅ Use only non-perfumed and non-soap based products on your vulval area, such as emollient washes; it is also an option to use water alone. Always make sure to dry yourself fully after washing.
✅ Wash your underwear using non-perfumed, gentle and non-biological laundry detergents. It is best to avoid fabric conditioners when washing intimate garments.
✅ Always wipe from front to back after using the toilet.
✅ Have showers rather than baths. If you are going to have a bath, ensure that the water is not too hot and avoid using perfumed bubble baths and bath soaks.
✅ Opt for breathable cotton undergarments. Some women may not realise that they are allergic to fabric dye, so choose white underwear when and if you can. If possible, do not wear underwear while sleeping.
✅ Always remove wet bathing suits and sweaty gym clothes as soon as possible. Chlorine from swimming pools can upset the vagina’s fragile microflora; using an emulsifying ointment around the vulva before swimming can be helpful as a protective barrier.
✅ Only use pH-balanced intimate lubes which are free from glycerine, glycols and parabens. These additives can increase vaginal dryness and make you more susceptible to catching vaginal infections, such as thrush. If you are using lubricated condoms, ensure that they are also free from such additives.
✅ If you have diabetes and are struggling to control your blood sugar levels, make an appointment with your GP and/or diabetes team for advice. Higher blood sugar levels help the Candida fungus to multiply and even small improvements in your blood sugar can make a big difference when it comes to thrush.
✅ Stress and being overly tired can reduce the body’s ability to keep the Candida fungus at bay and ward off infection. If possible, try to exercise regularly and get a full night’s sleep each night (at least 7 hours is recommended). Take part in activities that help you relax and unwind as often as possible.
✅ Although the link between the combined oral contraceptive pill and thrush is unclear, there are many different options for birth control that you and your doctor can explore together. Making an appointment to discuss alternative birth control options might be particularly helpful for women who have started getting thrush or feel that their thrush has gotten worse and/or occurs more frequently since starting the combined pill.
What if I am pregnant or breastfeeding?
It is common to develop thrush while pregnant and having a thrush infection will not harm your baby. However, it is important that you see your GP or midwife for anti-thrush treatment, rather than treating yourself.
This is because the treatment for thrush is likely to be different while you are pregnant or breastfeeding. It is recommended that intra-vaginal anti-thrush medications alone (e.g. pessaries or creams) are used to treat singular thrush infections, and as the “maintenance course” of treatment for recurrent thrush, for all women who are pregnant or breastfeeding.
Does my partner need to be treated for thrush?
It is possible for thrush to be passed between partners during sexual intercourse, although this is not common. If your partner does not have any symptoms of thrush, he/she does not need to be treated. However, if you or your partner are concerned about any possible symptoms of thrush, it is always best to consult a healthcare professional for appropriate diagnosis and treatment.
Common symptoms of genital thrush in men include:
⭐ Irritation, itching, swelling, redness and/or a burning sensation around the head of the penis and/or under the foreskin
⭐ Pain on pulling back the foreskin
⭐ White discharge from the penis
⭐ Pain on passing urine and/or sexual intercourse
⭐ An unpleasant odour around the genital region
Conclusion
Recurrent vaginal thrush does not usually cause any long-term health problems for women. However, if you struggle with repeated episodes of thrush, it might affect your mood, sexual relationships and overall quality of life.
The most important step in tackling recurrent thrush is to make an appointment with a healthcare professional who can help you identify any factors which might be pre-disposing you to thrush infections and prescribe the best treatment regimen for you. Treatment is most likely to be successful if you follow all of your doctor’s instructions carefully and complete the full course.
If you continue to struggle with recurrent episodes of thrush despite adequate treatment, your GP can refer you to a specialist gynaecology or genitourinary medicine (sexual health) clinic. However, the good news is that most women with recurrent thrush experience at least some reduction in the frequency and/or severity of episodes if treatment is completed appropriately.
References
(1) Torcia MG. Interplay among vaginal microbiome, immune response and sexually transmitted viral infections (2019). Int J Mol Sci; 20. DOI: 10.3390/ijms20020266.
(2) Candida: Female Genital. Scenario: Recurrent Infection. National Institute for Health and Care Excellence. Last revised: May 2017. https://cks.nice.org.uk/topics/candida-female-genital/management/recurrent-infection/#general-advice-on-self-management
(3) British Association for Sexual Health and HIV National Guideline for the Management of Vulvovaginal Candidiasis (2019). British Association for Sexual Health and HIV (BASHH). Published: 2019. https://www.bashhguidelines.org/media/1223/vvc-2019.pdf
(4) Recurring thrush: Why do I Keep Getting it? Lloyds Pharmacy. Published: April 2020. https://lloydspharmacy.com/blogs/womens-health/recurring-thrush
(5) Recurrent vulvovaginal candidiasis. Authors: Annabel Lines, Inna Vardi-Flynn and Clare Searle. BMJ. Published: June 2020. https://www.bmj.com/content/369/bmj.m1995
(6) Thrush in Men and Women. NHS. Published: November 2017. https://www.nhs.uk/conditions/thrush-in-men-and-women/
(7) Vaginal Thrush. Author: Mary Harding (Reviewed by Hannah Gronow). Patient.info. Published: July 2017. https://patient.info/sexual-health/vaginal-discharge-female-discharge/vaginal-thrush-yeast-infection
(8) Treating Recurrent Thrush. Author: Mary Harding (Reviewed by Hannah Gronow). Patient.info. Published: July 2017. https://patient.info/sexual-health/vaginal-discharge-female-discharge/treating-recurring-thrush
(9) Is Your Lifestyle Giving You Thrush? Author: Sally Turner (Reviewed by Sarah Jarvis). Patient.info. Published: January 2019. https://patient.info/news-and-features/is-your-lifestyle-giving-you-thrush