Vaginal Candiasis, or Yeast Infection

Overview

Vaginal infections are responsible for an estimated 10% of all visits by women to their health care practitioners. There are three general categories of vaginitis; hormonal, irritant and infectious. Hormonal vaginitis includes the atrophic vaginitis usually found in postmenopausal or postpartum women, but occasionally in young girls before puberty. Irritant vaginitis can be due to allergies including condoms, spermicides, deodorants, soaps, perfumes, semen, or douches. Irritants may also be due to hot tubs, mechanical abrasion, sanitary napkins, tampons, toilet tissue, topical medications, or foreign bodies. All of these may cause vaginitis. More than 90% of vaginitis in reproductive-age women is due to an infectious cause of one of three types: bacterial vaginosis, candidiasis, or trichomoniasis. There are other less common infectious causes like gonorrhea, chlamydia, mycoplasma, herpes, campylobacter, and even parasites like pinworms and giardia.

Candida vaginitis

In the United States, currently, Candida is the second most common cause of vaginal infections. Candida albicans is the most common organism in vulvovaginal candidiasis (VVC). There are more than 150 species of Candida, although only nine are considered to be clinically significant in humans. In recent years, the non-albicans species seem to be occurring increasingly and this may be due to the 1-to-3 day drug treatments that effectively suppress Candida albicans but may facilitate the overgrowth of non-albicans species. In the end, this may make it more difficult to treat VVC. Some women who culture positive for Candida do not have any symptoms of vaginitis. Candida is a normal part of the vaginal flora until some mechanism triggers the process into a symptomatic condition.

Acute itching and vaginal discharge are the usual presenting symptoms of VVC. The discharge is typically described as cottage cheese-like in character but it may actually vary from watery to thick. Symptoms may also include vaginal soreness, irritation, vulvar burning, inflammation and swelling of both the internal and external genital tissue, redness, pain with vaginal sexual activity and urinary discomfort. The symptoms are often worse the week preceding the onset of menses with some relief after the menstrual flow.

Unfortunately, self-diagnosis of VVC by women is unreliable too much of the time, making it even that more questionable that so many over-the-counter self-treatments are available. In a study assessing the ability of women to accurately self-diagnose yeast infections without the benefit of potassium hydroxide or culture confirmation, 2 out of 3 women misdiagnosed vulvovaginal candidiasis. (1) The most Candida-specific symptom is itching without discharge, and even this criterion correctly predicts VVC in only 38% of patients. (2)

The greatest concern in self diagnosing and self-treating VVC is in women who have recurrent VVC, which is defined as four or more Candida-confirmed episodes of symptomatic infection within 1 year. This occurs in approximately 5% of women. (3) Recurrent VVC commonly affects women who are immunocompromised as the result of AIDS or other predisposing conditions such as diabetes, Cushing's disease, Addison's disease, hypo- or hyperthyroidism, leukemia. The danger then, is that the underlying condition goes undiagnosed and is delayed in diagnosis because the woman is repeatedly treating herself for what she thinks are simple vaginal yeast infections. There are other predisposing factors in causing recurrent infections that may also need to be addressed: High-estrogen medication, antibiotics, hormones, contraceptive devices, cytotoxic drugs, immunosuppressive drugs, radiotherapy or chemotherapy, tight clothing, nylon underwear, pregnancy and excessive sugar in the diet. Reinfection may also come from extravaginal sources. Although the sexual transmission of Candida is still considered controversial, there is evidence that sexual transmission might be a likely source of recurrent infection.

Even more controversial is whether reinfection can occur from an intestinal reservoir. Many alternative practitioners address chronic Candida vaginitis by also addressing the possibility of migration from rectum to vagina and therefore treating the overgrowth of candida in the digestive tract. Although numerous studies have failed to yield definitive results, it may provide a useful avenue of treatment in especially chronic and resistant cases. (4)

Prevention Concepts

Preventing infections is almost always better than treating them. Here are some simple strategies that have been associated with reducing the frequency of VVC:

* Tight clothing can predispose the wearer to candidiasis. (5)

* Women who wear panty hose have about three times more yeast vaginitis infections than non-wearers. (6)

* Support a healthy vaginal ecosystem and immune system by having a generally whole foods diet and very little to no sugar and refined carbohydrates. There has been no good research data on the association of diet with VVO with the exception of acidophilus yogurt. That being said, a woman with a chronic condition presents a good opportunity to be coached in improved nutritional habits that will have many lifelong health benefits.

* Consider food, pollen, clothing detergent and semen allergies.

* Increase intake of acidophilus yogurt and/or take supplemental lactobacillus supplements when using antibiotics.

* Consider using condoms to prevent all types of vaginitis and using condoms until treatment regimen is complete to prevent recurrence.

Overview of Alternative Treatments

An important aspect of treating yeast vaginal infections is looking at the problem as one of host susceptibility rather than just using an anti-fungal approach. To this end, I recommend attending to the vaginal immune system: enhance general immunity, restore the proper balance of normal microflora in the vagina, restore the normal pH of the vagina, decrease the inflammation and irritation of the tissue itself, provide symptomatic relief, and when necessary, curbing the population and overgrowth of the offending organism. Although this approach sounds basic and logical, it is radically different than the conventional approach which is essentially to kill the overgrowth of the causative organism. Although in severe acute cases, pharmaceutical anti-fungals may ultimately be necessary, there is evidence that the organisms are becoming resistant to overuse of these products and newer and stronger products continually need to be developed in order to deal with these resistant strains. So, even when the pharmaceuti cal over-the-counter medications or prescription medications need to be used, the principles and methods of some of the natural treatments can be an important part of a healthy vaginal ecosystem and immunity for the future.

The vaginal microflora of healthy asymptomatic women consists of a wide variety of anaerobic and aerobic bacteria dominated by Lactobacillus. The range of bacterial types isolated is immense, including Staphylococcus species, Gardnerella vaginalis, Streptococcus species, Bacteroides species, Lactobacillus species, Mobiluncus, even Candida species, most commonly Candida albicans, and more. Again, the predominant organisms isolated from the normal vagina are members of the Lactobacillus genus. There are over 140 Lactobacillus strains but in the normal vaginal flora, there are usually two or three species - the most common being Lactobacillus plantarum, L fermentum and L acidophilus. Using molecular biology methods, it has been found that L acidophilus is actually not the predominant species. (7) In addition, the diversity of Lactobacillus species and the density of Lactobacillus organisms in the vagina can be correlated with the age and health status of the patient. The presence of Lactobacillus is fundamental to maintaining the proper p11, antagonizing the growth of potentially pathogenic bacteria, and preventing adherence of the bacteria to the vaginal wall. The antagonistic mechanisms of Lactobacilli are dependent on the ability to maintain the acidic pH of the vagina, (caused by products of carbohydrate fermentation - lactic acetic, propionic and pyroglutamic acid), (8) the production of specific antibacterial bacteriocin-like substances such as lactocin and acidophilin, and the production of hydrogen peroxide. (9) Not all Lactobacillus species produce hydrogen peroxide. One study attempted to show which species found in different yogurt products, do produce hydrogen peroxide.' (10) L delbrueckii subsp bulgaricus isolates, two of four L acidophilus and five of nine L casei subsp rhamnosus were 11202 producers.

Alternative Treatments

Dietary Factors

It cannot be overemphasized how the health of the entire body affects the internal ecosystem of the vagina. The pH of the vagina, the microflora that live there, the hormonal cycles, and the immune tissue in the vagina are all influenced by our general health and our dietary habits and this in turn determines how susceptible we are as a host for the overgrowth of the unfriendly organisms that cause the vaginitis. A generally healthy diet assures our body's defense system. A diet low in sugars and refined carbohydrates may be important in preventing candida vaginitis by providing less fuel for its reproduction and growth. In general, a well balanced whole foods diet that is low in fat, sugars, refined foods and alcohol is most likely optimal in preventing all infections. Some women who have severe stubborn cases of chronic candida vaginitis may benefit from stricter diets that avoid fermented foods. These "anti-candida" diets can be rigorous and stressful and most of the time are not necessary.

Garlic (Allium sativum)

Garlic extracts have been shown to inhibit the growth of Candida albicans by blockage of lipid production which thereby inhibits growth. (11) The major growth inhibitory component in garlic extract is allicin and garlic products that have the highest amount of allicin would be the most desirable. Garlic is diverse in its uses for vaginitis because it is both antibacterial and antifungal. (12,13) Although I am not aware of any research on the use of garlic inserted in the vagina, this has consistently been one of my recommendations for women over the years for both candida (yeast) vaginitis and bacterial vaginosis. A carefully peeled clove (so as not to nick the garlic) can be inserted into the vagina for 6 to 8 hours. The garlic can be threaded like a necklace so that it can be easily removed as if it were a tampon. "Garlic tampons" or garlic capsules can be inserted intravaginally in the evening and then lactobacillus capsules can be inserted later to create a plan that both inhibits growth of the offending organism and repopulates the microflora to a normal healthy state.

Goldenseal (Hydrastis canadensis) and Oregon grape (Berberis vulgaris)

Goldenseal and Oregon grape roots contain a substance called berberine which acts both as an antibacterial and immune enhancer. This immune effect is especially specific in epithelial mucus membrane tissue as is found in the vagina, mouth, and even the stomach. Berberine has been shown to possess antimicrobial activity against a wide variety of microorganisms some of which are found in the vagina, such as Candida albicans, Escherichia coli, Staph aureus and others. (14) Preparations of goldenseal and oregon grape have been used both orally in teas, caps and liquid extracts, and intravaginally in douches and suppositories. Because of its ability to affect both yeast and bacteria, these two herbs would seem a logical choice in cases where multiple infectious agents are involved.

Lactobacillus

Although we often think of only Lactobacillus acidophilus, several species populate the vagina. The predominant species of Lactobacillus isolated from the vagina of healthy women remains controversial although as stated earlier, L fermentum, L plantarum and L acidophilus are at least three of the dominant species. Several mechanisms are possible for how Lactobacillus does its remarkable job. A low vaginal pH is believed to be a primary mechanism controlling the composition of the vaginal microflora. Lactic acid is produced by the metabolism of lactobacillus and although there may be other ways in which the vagina maintains its normal acidic environment, the role of lactobacilli seems evident. Lactobacilli thrive at an acidic pH of 3.5 - 4.5 and these values are indeed found in the normal vagina throughout the menstrual cycle. Lactobacilli have also been shown to interfere with how pathogenic (disease causing) bacteria adhere and colonize the cells of the vagina. (15)

The concept that lactobacilli might be useful when supplied in the diet, as a supplement or intravaginally dates back to the 1890s. While scientists have vacillated on the value of lactobacilli in prevention or in treatment, patients in need have not. In fact, Lactobacillus therapy is quite popular both with alternative practitioners and with women who seek simple self-treatment methods. A study was done in 1992 on the daily ingestion of yogurt containing Lactobacillus acidophillus in women with recurrent candidal vaginitis. In the women who ate 8 oz daily of the yogurt, there was a threefold decrease in infections in candidal colonization when compared to the women who did not eat the yogurt. (16) It is now also popular to ingest lactobacillus acidophilus supplements in oral form in place of or in addition to eating yogurt. Another method that is popular is the application of lactobacilli directly into the vagina. Douching used to be a popular method but since research has shown that douching may contribute to infertility and pelvic infections, a safer and more convenient method is available by introducing lactobacillus capsules or tablets into the vagina. (17) Alone or in combination with other vaginal or oral therapies, Lactobacillus is the key to establishing normal vaginal microflora, preventing recurring infections, as well as treating acute Candida and bacterial infections of the vagina.

Doubts about the effectiveness of Lactobacillus supplements have been raised often. Perhaps the most damaging evidence was a study that examined 16 generally available nonprescription Lactobacillus products, including dairy products. (18) Products were checked to see if the type and quantity of bacteria claimed for the products were actually present. The study disappointingly found that only four of the 16 products tested had Lactobacillus acidophilus. Of the four, only two contained strains that produced hydrogen peroxide, (necessary to achieve the acidifying effect) and they had contaminants in them. Even though the authors of this 1990 study concluded that recommending lactobacillus was not warranted, women have continued to use it, and many with a great deal of success, it seems. We can hope that the technology in developing these products has improved since 1990 and many companies do in fact offer verification of analyzed ingredients in their lactobacillus products to confirm their quality. I recommend l ooking for products that have been documented to produce H202 and products that contain a combination of at least three of the following: L acidophilus, L fermentum, L plantarum, L bulgaricus, L casei and L rhamnosus.

Boric Acid

Nothing impresses me more than the success rate of boric acid suppositories for the treatment of Candida vulvovaginal infections. In one study of 100 women with chronic resistent yeast infections who had failed extensive and prolonged conventional therapy, were treated with 600mg boric acid vaginal suppositories twice a day for two weeks or four weeks. This regimen was effective in curing 98% of the women who had previously failed to respond to the most commonly used antifungal agents. (19) Clinical effectiveness doesn't really get any better than this: It works most of the time, it's inexpensive, it's easy to use. The only down side I have observed is that if the tissue has been irritated enough by the infection, the boric acid as the capsule melts, can cause burning. Using vitamin E oil or lanolin or even vaseline on the external genitalia to protect it from the boric acid seems to avert any significant discomfort.

Sample Treatment plan for Yeast Vaginitis

Acute:

* Avoid sugars and refined carbohydrates, alcohol

* Eat 8 oz. Acidophilus yogurt daily

* Lactobacillus capsules, at least 6-10 billion organisms per day

* Boric acid powder capsules; Insert a.m. and p.m. for 3-7 days in mild cases and up to 14 days for resistant cases

Chronic:

* Avoid sugars, refined carbohydrates, alcohol, fermented foods

* Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus capsules, 3 caps twice daily

* Garlic capsules; 1 cap one to two times daily by mouth

* Boric acid powder capsules; Insert a.m. and p.m. for 14 days. Repeat for an additional 14 days if responding but not completely resolved after the first 2 weeks

Consider combination anti-candida products that contain numerous known anti-fungal and immune modulating nutrients (ex/caprylic acid, garlic, Oregon grape, golden seal, lactobacillus, milk thistle, grapefruit seed, vitamin E)

Prophylaxis (Prevention of recurrence)

* Avoid sugars, refined carbohydrates, alcohol, fermented foods

* Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus 2 capsules daily

* Garlic capsules; 1 cap daily by mouth

* Boric acid powder capsules; Insert 1 capsule daily at bedtime, during menstruation only for 4 consecutive months

* Consider combination anti-candida supplement products

During pregnancy:

* Avoid sugars, refined carbohydrates, alcohol, fermented foods

* Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus capsules 2-4 caps daily

* Garlic capsules; 1 cap daily by mouth