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Continuing Professional Development
COUNSELLING IN PRACTICE
either clotrimazole 500 mg pessary, oral
fluconazole 150--300 mg, itraconazole
capsules 100--200 mg, or nystatin
vaginal cream. Up to 50% of women
relapse within 12 months of cessation of
For VVC caused by other Candida species,
the patient should consult a specialist.
C. glabrata, the most common cause of
non-albicans VVC, is resistant to topical
azoles and may require longer courses of
oral fluconazole or treatment with other
agents. For example, boric acid 600 mg
(extemporaneously prepared in a gelatin
capsule) intravaginally once daily for
10--14 days is effective in approximately
70% of patients.6,13,14
How must I use the medication?
The pharmacist should explain how
the selected treatment must be used,
including frequency of application,
duration of therapy, the importance of
completing the full course of treatment
even if the symptoms disappear, and any
specific precautions. Vaginal creams and
pessaries should be applied at night, just
before going to bed. The woman should
be told to lie on her back with knees
bent, gently insert the plastic applicator
containing the cream or pessary as
deeply into the vagina as is comfortably
possible, and then depress the plunger.
If desired, pessaries can be inserted
digitally (may be the preferred method
during pregnancy). If treatment during
However, the woman should be informed
about the lack of evidence to support
What if I get VVC while I'm
Topical azoles are more effective than
nystatin and are the preferred treatment
for VVC in pregnancy. A seven-day course
may be necessary. A four-day course will
cure just over half of infections, whereas
a seven-day course cures over 90%.
Clotrimazole and miconazole are category
A and are safe to use. Butoconazole
is category B3 and, although topical
application is unlikely to cause any
adverse effects, it may be preferable to
use one of the other azoles. Pregnant
women should be advised to exercise
caution when inserting the vaginal
applicator, especially during the third
trimester. Although oral fluconazole
is category D, a single 150 mg dose is
unlikely to pose a risk to the fetus and can
be used if topical azoles are unsuitable
Do I need to see my doctor?
A woman requesting treatment for
vaginal thrush or complaining of vaginal
discharge or vulvovaginal symptoms
should be referred to a doctor if 5,17:
• She has not previously had a
medically-diagnosed episode of VVC.
The accuracy of self-diagnosis is 36%
in women who have had a previous
episode of VVC and only 9% if there has
been no previous episode. Empirical
treatment of suspected VVC may
delay the treatment of another, more
• Her symptoms have not responded to
an appropriate course of treatment.
• She has recurrent episodes (≥4 a year)
or persistent symptoms.
• She has any of the following signs/
-- fever, malaise
-- pain or burning on urination,
frequency and/or urgency
-- pelvic or abdominal pain
-- abnormal or irregular vaginal
bleeding or spotting
a menstrual period is unavoidable, the
woman should be advised to use sanitary
pads instead of tampons. Because topical
azoles can damage latex condoms,
diaphragms and cervical caps, these
contraceptive methods should not be
relied on during treatment.17
Should my partner also receive
Routine screening or treatment of sexual
partners is not necessary, as vaginal
candidiasis is not a sexually-transmitted
infection. Sexual partners who develop
symptoms should be swabbed and
only treated if cultures are positive.
If a male partner describes discomfort
soon after intercourse, this may be
an irritant effect that can be relieved
by use of an azole cream containing
Is there anything I can do to avoid
getting VVC again?
The following strategies may help to
reduce the severity of symptoms and the
risk of further episodes of VVC5,17--19:
• Avoid using soap to wash the genital
area. Use a soap substitute and
dry the area gently but thoroughly
• Avoid using antiseptics and perfumed
soaps, shower gels or bath oils in the
• Wear cotton underwear and
loose-fitting clothing. Avoid synthetic
underwear and nylon pantyhose.
• Avoid having sexual intercourse during
an episode of VVC.
• Do not use tampons or vaginal
douches, powders or deodorants.
• After a bowel movement, wipe from
front to back to avoid spreading bowel
microbes from the anus to the vagina.
There is currently no conclusive
evidence to support the use of oral
or vaginal probiotics to prevent VVC.
Probiotics have few adverse effects,
and products containing L. acidophilus,
L. rhamnosus GR-1 or L. fermentum
RC-14 may be considered as empirical
preventive therapy in women who have
frequent recurrences (≥4 episodes a
year), especially if antifungal medicines
are contraindicated or not tolerated.
or treatment of
sexual partners is not
necessary, as vaginal
candidiasis is not a
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