Michelle couldn’t believe it. It was 11 pm Thursday night and she was feeling itching and burning in her vagina. She started feeling symptoms yesterday and to ward off the yeast infection Michelle had eaten three yogurts and for good measure drank one-half gallon of cranberry juice. Didn’t help. Now she felt like she was really on fire. The timing couldn’t be worse. She was planning to leave on Friday afternoon for a romantic weekend she and her husband, Scott, have been looking toward. Michelle was frantic with indecision. Didn’t know what to do. Should she call her gynecologist? Would her gynecologist even see her tomorrow – even if she begged? Should she go to an all-night pharmacy and get a yeast cream? What!!!!

Almost all women, at least once in their lives, experience the symptoms of vaginal itching, burning, and discharge. It is common wisdom that these symptoms are diagnostic of a yeast infection caused by the fungus, Candida, albicans or other Candida species such as glabrata and tropicalis. However, recent medical studies have shown that the majority of women who have these symptoms do not have a yeast infection. If it isn’t a yeast infection, what else might it be? To answer this question we need to discuss the symptoms of itching, burning, and discharge.

You feel terrible itching and burning. It feels like you have a thousand mosquito bites in your vagina and in fact it’s quite similar. When a mosquito stings it injects a chemical called histamine into the bite. Histamine reacts on nearby nerve endings to cause the sensation of itching and burning. But, of course, you didn’t get a thousand mosquito stings in your vagina so what’s going on? Anything that causes inflammation in the vagina causes your body to release histamine, which leads to the symptoms of itching and burning.

So what causes inflammation? Of course, yeast infections can cause inflammation, but other types of infections can cause inflammation as well. The term vaginitis refers to any infection or inflammation in the vagina. Studies have shown that in addition to vulvovaginal candidiasis other common forms of vaginitis are bacterial vaginosis and Trichomonas. The most common causes of infection are by bacteria called bacterial vaginosis. Approximately 30 to 35% of all vaginitis is caused by an overgrowth of bacterial vaginosis in the vagina. Bacterial vaginosis is caused by many different species of bacteria and has been known by many names including Gardnerella, haemophilis vaginitis, corynebacterium vaginitis and nonspecific vaginitis. In addition, an organism called Trichomonas causes 10% of all vaginitis. Trichomonas is caused by a protozoan organism and is usually acquired during intercourse.

But, infections are also not the only cause of inflammation. Ten percent of all vaginitis is caused by chemical or allergic reactions. Perfumes and dyes in soaps or bubble baths, spermicides or lubricants, laundry detergents and fabric softeners can cause inflammation, irritation, or allergic reactions that stimulate the release of histamine. Only 20 to 25% of all vaginitis is caused by yeast infections. A medically-untrained patient making the correct diagnosis of vulvovaginal candidiasis is highly unlikely. Most women are aware of VVC yet few are aware of the symptoms of bacterial vaginosis, Trichomonas, or chemical inflammation.

Approximately 15 to 20% of all vaginitis is actually a combination of two or more of the other types of vaginitis. Because most women are aware of yeast infections, but not aware of bacterial vaginosis and Trichomonas, there is a tendency for women to consider vulvovaginal candidiasis as the cause of their vaginal symptoms and not the more common diagnosis of bacterial vaginosis.

The following facts were underscored by a study reported in the Journal of Obstetrics and Gynecology in 2002. In this study 95 women were stopped in a pharmacy as they were about to purchase an over-the-counter yeast medication. They were offered the opportunity to go to a doctor’s office and have an accurate diagnosis made at that time. Of those ninety-five women who self-diagnosed vulvovaginal candidiasis, only 33 percent were actually found to have a yeast infection. The majority of women had either bacterial vaginosis or a mixed infection. Therefore they would not have been properly treated with the over-the-counter yeast medication they had planned to purchase. As importantly, women who had been previously been diagnosed with yeast infection were no more likely to be able to self diagnose a yeast infection than those women who had never been told they had a prior yeast infection.

This study underscores the important fact that the symptoms of any type of vaginitis are non-specific. Just because you’ve had a prior yeast infection doesn’t mean that your symptoms indicate a yeast infection. An examination by a healthcare profession is essential to make the accurate diagnosis. Your doctor cannot make the diagnosis of a yeast infection over the phone. Symptoms of itching, burning, and cottage cheese-like discharge do not mean you have a yeast infection. Only a healthcare professional has the diagnostic tools and the experience to make an accurate diagnosis and this must be done in person. To differentiate among the three most common types of vaginitis a physical examination should be performed. In addition, a microscopic examination of the vaginal secretions is absolutely essential as well as measuring the pH of the vaginal secretions. Additional tests may be necessary to make an accurate diagnosis.

When you do go to your healthcare provider’s office the first thing the doctor will do is ask you your symptoms. As we said before symptoms are generally non-specific to yeast infections; however, some symptoms do give your doctor a clue as to what type of vaginitis you have. Itching, soreness, and pain during intercourse are more likely to be a yeast infection than bacterial vaginosis. Symptoms of a malodorous discharge without pain during sex are more likely to be bacterial vaginosis and symptoms of a malodorous vaginal discharge with pain during sex are more likely to be Trichomonas. Next, your healthcare provider will do a physical examination. Again, there may be some clues on physical examination that may point towards a yeast infection as opposed to a bacterial vaginosis or a Trichomonas. Redness of the labia, swelling of the labia, and cracks or fissures of the labia are more likely to be a yeast infection that bacterial vaginosis.

If there is a sticky-adherent discharge it is more likely to be a bacterial vaginosis or Trichomonas. Your healthcare provider will then test the pH of the secretions. A pH of 4 to 4.5 is more likely to be vulvovaginal candidiasis while a pH of greater than 4.5 is more likely to be bacterial vaginosis or Trichomonas. However, as we pointed out earlier, approximately 15 percent of all vaginitis are a mixed infection and therefore these rules may not hold true.

The next thing your healthcare provider should do is perform a microscopic examination. This is the quickest and cheapest test that your doctor can perform to make an accurate diagnosis of vaginitis. Under the microscope your healthcare provider can see yeast cells called hyphae if your vaginal secretions are first treated with a solution of potassium hydroxide. If your healthcare provider is not able to accurately diagnose what type of vaginitis you do have by evaluation of your vaginal secretions, it is essential that a culture be performed. While all cultures do not give immediate diagnoses, they are very accurate and will help prevent incorrect treatment.

If your doctor diagnoses bacterial vaginosis you will be given a prescription for an oral or vaginal (cream or gel) antibiotic, either metronidizaole or clindamycin. Be sure to follow your doctor’s directions thoroughly because failure to take the medicine as described can lead to a recurrence.

If your healthcare provider does diagnose a true yeast infection, there are many different treatment options for vulvovaginal candidiasis. There are both over-the-counter and prescription topical treatments for vulvovaginal candidiasis. In addition there is an oral medication approved for the treatment of vulvovaginal candidiasis.

Topical treatments come in many forms including vaginal creams, suppositories, and tablets. There are single-dose, three-day, or seven-day treatment regimens available. Topical treatments offer patients important benefits. When they are used correctly for the treatment of vulvovaginal candidiasis after an accurate diagnosis has been made they are very efficacious. Secondly, they are now available over the counter providing easy access to vulvovaginal candidiasis treatment. However, there are also areas of concern associated with topical treatments. For many topical treatments, women are advised not to rely on contraceptive devices that contain latex such as condoms because the creams contain oils that may weaken latex or rubber. This also includes the female condom and diaphragms. In addition, with topical products patients are advised to use sanitary napkins instead of tampons if menstruating. Topical products tend to be messy and most are recommended for use at bedtime. Topical products often contain chemicals that can cause allergic reactions or chemical irritations and therefore cause that type of vaginitis. If not used properly or for long enough, the infection will go untreated and may recur. If a woman uses one of these topical preparations but did not have a yeast infection, when she visits her doctor for further treatment a correct diagnosis may very difficult because the creams interfere with diagnosis under a microscope and can actually interfere with vaginal cultures as well. It is for these reasons that I generally prefer to use the oral medication for yeast infections.

Fluconazole, which is sold under the brand name, Diflucan, is a one-tablet treatment for vulvovaginal candidiasis. A 150 mg tablet is more than 90 percent effective for the treatment of yeast infections. Diflucan has proven extraordinarily safe in use and there has never been any evidence of systemic side effects such as liver toxicity with a single dose of Diflucan. The symptoms of a yeast infection start to disappear within 36 hours after taking the Diflucan tablet and should completely resolve within two days. Diflucan does not interfere with oral contraceptive pills nor does it interfere with other types of contraception such as condoms or diaphragm use.

Often Diflucan can be used in combination with topical steroid ointments such as triamcinolone, betamethasone, valerate and diprosone, which will quickly start to treat the inflammation of a yeast infection on the labia such that symptomatic relief from the yeast infection can be achieved within a matter of hours instead of waiting up to 36 hours for symptomatic relief.

Below is a chart describing some of the treatment options available. Discuss these options with your doctor to find the appropriate medication for you.

(Chart information taken from the Pfizer Powerpoint presentation: Taking a Closer Look at Topical Treatments for VVC; Pfizer at www.diflucan.com.)

Remember, when a woman encounters itching, burning, and discharge it is very important that she understands that there may be one of several different possible causes of these symptoms. It is therefore essential that she visit a healthcare provider for examination and diagnosis to make sure she gets the proper treatment.

And Michelle? She and Scott made the trip the following weekend, thanks to some quick rescheduling, and proper medical treatment

Additional resources on female sexuality are available from MayoClinic.com:

https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises/art-20045283
https://www.mayoclinic.org/diseases-conditions/yeast-infection/symptoms-causes/syc-20378999
https://www.mayoclinic.org/healthy-lifestyle/womens-health/basics/womens-health/hlv-20049411