Vulvovaginitis (inflammation of the vulva and vagina) most commonly occurs in reproductive-aged women secondary to infection. Candidal vulvovaginitis, otherwise known as a vaginal yeast infection, is responsible for about one-third of cases of vulvovaginitis. Up to 75% of women will experience at least one vaginal yeast infection in their lifetime, and 8% suffer from recurrent infections. (15, 20)
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What Is Vulvovaginal Candidiasis?
Vulvovaginal candidiasis (VVC), commonly known as a vaginal yeast infection, is a prevalent condition caused by an overgrowth of fungus in the vaginal area, leading to inflammation. Yeast is a type of fungus. Along with bacterial infections, yeast infections are among the most common causes of vaginal inflammation. Candida, a variety of yeast, is a naturally occurring microorganism found in small amounts in the vagina. Various factors can disrupt the delicate balance of the vaginal microbiota, allowing Candida to overgrow and cause an infection. (20)
Vulvovaginal Candidiasis Signs & Symptoms
The symptoms of yeast infections can range in severity from mild to severe and include:
- Thick, white vaginal discharge (often described as having a "cottage cheese" appearance)
- Itching and burning in the vagina and vulva
- Pain during urination and sexual intercourse
- Redness and swelling of the vulva
Women with VVC have a normal vaginal pH, ranging between 4-4.5.
In severe cases, patients may get fissures or sores on their vagina or vulva.
Root Causes of Vulvovaginal Candidiasis
The two most common strains of Candida responsible for causing VVC are Candida albicans (90% of infections) and Candida glabrata (15).
Several factors contribute to the overgrowth of Candida. The most common cause is a disturbance in the vaginal microbiota, which can occur for various reasons. These include the use of broad-spectrum antibiotics that kill off beneficial bacteria, hormonal fluctuations during the menstrual cycle or pregnancy, uncontrolled diabetes, a weakened immune system, and high levels of stress. (6)
Certain lifestyle factors may increase the risk of developing yeast infections. These include a diet high in refined sugars and carbohydrates, which can promote yeast growth, as well as frequent or excessive use of feminine hygiene products; douching; wearing tight, non-breathable clothing; and prolonged use of oral contraceptives. (9, 34)
How to Diagnose Vulvovaginal Candidiasis
Research indicates that self-diagnosis of VVC is often inaccurate, with only about one-third of women correctly identifying the condition when attempting to diagnose vaginal symptoms themselves. Therefore, any patient who suspects they have VVC should schedule an appointment with their doctor to receive the appropriate testing.
Step 1: Candida Identification
In patients with hallmark symptoms, VVC can be confirmed by visualizing yeast hyphae on a potassium hydroxide preparation (KOH prep). To do this, doctors or patients will collect a sample of vaginal discharge, which is then placed on a slide with a drop of 10% KOH solution. The slide is examined under the microscope for budding yeast or hyphae. Microscopy is negative in 50% of cases.
A vaginal culture is indicated in the following scenarios:
- Normal microscopy with clinical suspicion of VVC
- Recurrent VVC (four or more infections in one year)
- Unresponsive to treatment
The Vaginosis Profile by Doctor's Data is a test that includes a yeast culture, screens for bacterial vaginosis (another vaginal infection that can cooccur with VVC) and performs antimicrobial susceptibility testing.
Step 2: Order Labs to Understand the Root Cause of VVC
Your doctor may also recommend ordering additional labs to identify predisposing factors to infection (especially in patients with recurrent VVC) and personalize treatment options.
Microbiome Testing
The female gut and genital microbiotas have a complex and interconnected relationship that can influence each other's composition and overall health. Therefore, patients with recurrent yeast infections may benefit from a more comprehensive microbiome evaluation through vaginal and stool testing, which can identify chronic dysbiotic patterns predisposing a patient to infection recurrence.
Examples include:
- Vaginal BiomeFx by Microbiome Labs
- GI-MAP by Diagnostic Solutions
Immune Function
Because a weakened immune response increases the risk of yeast infections, your doctor may recommend ordering these tests to assess the integrity of the immune system in determining the underlying causes of recurrent VVC:
- A complete blood count, such as CBC with Differential and Platelets by Access Labcorp Draw, measures the various types of white blood cells in circulation. Changes in white blood cells' total number or distribution can indicate immune suppression.
- The Lymphocyte MAP by Cyrex Laboratories measures the integrity of the immune system at the cellular level by identifying key lymphocyte biomarkers, providing a picture of the underlying conditions triggering immune deficiency.
Diabetes Panel
People with type 1 and type 2 diabetes are at a higher risk for yeast infections because chronic elevations in blood sugar levels create an environment conducive to yeast overgrowth and compromise the immune system's ability to fight infections effectively (31).
Hemoglobin A1c is the standard biomarker for diagnosing and monitoring diabetes, but additional labs can be helpful to better understand an individual's metabolic health and glycemic control. A comprehensive diabetes panel could include the following tests:
- Comprehensive Metabolic Panel by Access Med Labs
- Hemoglobin A1c (HbA1c) by ZRT Laboratory
- Insulin, Fasting by Access Labcorp Draw
- HOMA-IR w/ Beta Cell Function by BostonHeart Diagnostics
Comprehensive Hormone Panel
Estrogen dominance may cause recurrent VVC because of estrogen's control over glycogen (sugar) production in the vagina.
Chronic stress suppresses the immune system, causes dysregulation of female sex hormones, and contributes to intestinal dysbiosis by altering gastrointestinal motility. A higher incidence of VVC has been noted in women with a blunted cortisol awakening response (CAR), a sign of chronic stress.
The following panels can offer insight into underlying reproductive and stress hormone imbalances contributing to VVC risk:
- DUTCH Plus by Precision Analytical (DUTCH)
- Saliva Female Hormones Plus by Ayumetrix
- Cortisol Awakening Response Profile by ZRT Laboratory
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Treatment Plan for Vulvovaginal Candidiasis
Once VVC has been diagnosed, a comprehensive treatment plan can be implemented to eradicate Candida overgrowth and restore vaginal homeostasis to prevent infection recurrence.
Step 1: Treat Yeast Overgrowth
Here's Why This Is Important:
Fungal eradication alleviates the uncomfortable symptoms associated with VVC.
How Do You Do This?
The CDC recommends using one of the following topical or oral azole medications for first-line treatment of VVC:
- Clotrimazole 1% or 2% cream
- Miconazole 2% or 4% cream
- Miconazole vaginal suppository
- Butoconazole 2% cream
- Terconazole 0.4% or 0.8% cream
- Terconazole vaginal suppository
- Oral fluconazole
The duration of treatment will depend on the agent used but generally ranges anywhere from one to seven days. In nonpregnant women, there is no preferred treatment option, and all possibilities have about an 80% cure rate. Only topical therapies, applied for seven days, should be recommended to pregnant patients. (21)
Boric acid has emerged as a notable alternative treatment option for vaginal yeast infections, particularly for cases that are recurrent or resistant to standard antifungal therapies. The treatment involves inserting 600 mg of boric acid into the vagina daily for 3-21 days, depending on the chronicity of the infection. Studies have demonstrated that this regimen has success rates ranging between 40% and 100%. (14, 30)
Step 2: Prevent Infection Recurrence
Why Is This Important?
Additional treatment recommendations aimed to address underlying causes of infection and optimize vaginal health create a well-rounded, holistic treatment protocol that can enhance infection cure rates and prevent VVC recurrence.
How Do You Do This?
Many doctors recommend following a Candida diet to reverse and prevent yeast overgrowth. This diet eliminates certain foods, particularly refined carbohydrates, that potentiate inflammation and yeast growth. Proponents of the diet suggest that avoiding these foods can restore balance to the human microbiome, reduce systemic inflammation, and balance blood sugar – effectively preventing Candida overgrowth. Research studying the effects of dietary modifications on treating candidiasis is limited, but preliminary research suggests that making Candida diet-like dietary modifications during and after treatment with antifungals results in better clinical outcomes.
Foods to Eat
- Non-starchy vegetables: artichokes, broccoli, cabbage, cucumber, spinach, zucchini
- Low-glycemic fruits: avocado, berries, lemon, lime
- Non-glutenous whole grains: buckwheat, brown rice, millet, oats, quinoa
- Lean proteins: chicken, eggs, fish, legumes
- Some dairy products: butter, ghee, kefir, probiotic yogurt
- Low-mold nuts and seeds: flaxseed, hazelnuts, sunflower seeds
- Herbs and spices
- Healthy fats and oils: avocado, coconut, olive
- Sugar-free sweeteners: erythritol, stevia, xylitol
- Fermented foods: kimchi, pickled vegetables, sauerkraut
- Herbal teas (25)
Foods to Avoid
- Sugars: agave, aspartame, cane sugar, corn syrup, honey, maple syrup
- Gluten-containing grains: barley, rye, spelt, wheat
- High-glycemic fruits: bananas, dates, fruit juices, mango
- Processed meats
- Some dairy products: cheese, milk, cream
- Condiments: barbeque sauce, horseradish, ketchup, soy sauce, white vinegar
- Refined fats and oils: canola, margarine, soybean, sunflower
- Alcohol, soda, and energy drinks (24)
Probiotics are increasingly being recognized as adjunctive therapy to support the vaginal microbiome through their ability to reduce vaginal pH, restore and maintain a normal vaginal microbiota, produce antimicrobial molecules, and support the body's innate defenses against yeast cells. Lactobacillus is the most abundant microorganism in the vagina. There is evidence to support the effectiveness of oral and intravaginal lactobacilli, especially Lactobacillus acidophilus, Lactobacillus rhamnosus GR-1, and Lactobacillus fermentum RC-14, in preventing candidiasis.
The Risks of Untreated Vulvovaginal Candidiasis
A yeast infection can lead to more severe symptoms, such as increased itching, burning, and swelling, if left untreated. This can lead to a secondary skin infection if the affected area becomes raw and cracked.
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Key Takeaways:
- While yeast is a commensal microbe naturally found in the human microbiome in small amounts, overgrowth can cause infection and uncomfortable symptoms.
- Vulvovaginal candidiasis, or vaginal yeast infections, commonly causes vaginal inflammation and bothersome symptoms in women of reproductive age.
- A holistic treatment approach to treating VVC aims to treat infection, reduce vaginal symptoms, and address underlying factors predisposing an individual to infection. This root-cause treatment approach reduces the infection recurrence rate and promotes long-term vaginal health.
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