Recurring Vaginal Yeast Infection: Understanding and Managing the Chronic Cycle

Introduction

Vulvovaginal candidiasis (VVC) or colloquially known as vaginal yeast infection is a common fungal infection of the female lower reproductive tract infection. Recurring vulvovaginal candidiasis (RVVC) occurs when the vaginal yeast infection occurs 4 times or more per year. Vaginal yeast infection tends to present with abnormal vaginal symptoms such as itching and burning, abnormal vaginal discharge, pain, redness and irritation over the genital region.

Vaginal yeast infection is caused by a type of fungus known as Candida albicans. Less commonly, the condition can also be affected by other fungal strains such as Candida glabrata, Candida tropicalis, Candida krusei, Candida parapsilosisand etc. 

Intriguingly, Candida albicans can behave as commensal or healthy fungal colony. It also be found in the mucosal layer (inner skin layer) of the mouth, genital, or even the intestinal tract in 30-70% of healthy people without causing any harm. 

Question: When does Candida spp (yeast) start becoming pathogenic and opportunistic- causing infection? Why does one have a tendency of recurrence?

By grasping the reasons behind these key questions, only can we delve deep into the root and manage the condition effectively.

Understanding the vaginal natural barrier, the repercussion of weakened vaginal defense and presence of fungus cells

Healthy vaginal mucosal barrier

The vaginal mucosal epithelium is the first line defense against external pathogens including fungus such as Candida spp. A healthy vagina has an abundant good flora Lactobacillus spp. These bacteria keep the vaginal environment constantly in a low acidic pH, making the vagina hostile for micro-organism including bacteria and fungus to thrive. These healthy bacteria will also compete with Candida spp and preventing Candida spp from adhering onto the vaginal cells.

Interestingly, the vaginal layer produces a mucus natural barrier lining to prevent external micro-organism (including Candida spp) from sticking and invading the vaginal cell layer. The vaginal epithelial layer also undergoes regular shedding, removing any unwanted micro-organism that is adhered to the external layer, keeping the vagina microenvironment sterile.

Disruption of vaginal mucosal barrier

The natural vaginal barrier can be disrupted leading to disequilibrium of the vaginal microbiome and a depletion of Lactobacillus spp. With the protective bacteria and vaginal layer compromised, the vagina becomes susceptible towards various opportunistic micro-organism, allowing various bacteria, fungus, parasites to thrive, invade and infect the vaginal canal.

The fungal cells overwhelming  the threshold of vaginal mucosal tolerance

Up to 70% of healthy women without any vaginal symptoms may have Candida spp in the vaginal canal. Nonetheless, the weakening of the vaginal local defense mechanism coupled with excessive growth of Candida spp increases the ‘virulence ability’ of the fungus. (Virulence ability: the ability to invade and attack surrounding cells.) At one point, when the ‘virulence ability’ of the fungus surpasses the limit of the vaginal mucosal barrier, the vaginal epithelium breaks down, triggering a cascade of local vaginal inflammation.

Fungal cells become pathogenic

Furthermore, when there is an impaired vaginal mucosal lining the Candida spp cells are able to adhere to the vaginal cells, forming hyphae (finger projections) that facilitate the fungal cells to invade the vaginal cells. This, again, results in further inflammation of the vagina linings.

Uncontrolled vaginal local inflammation- the end point of abnormal vaginal symptoms

The body mounts an inflammation response against pathogenic Candida spp in an attempt to clear the infection off ineffectively. An uncontrolled, persistent local vaginal inflammation leads to clinical symptoms of vaginal discomfort, pain, itching, swelling and abnormal discharge.

Common Causes of Recurring Vaginal Yeast Infection

1. Unstable vaginal microbiome

This can be due to lifestyle habits such as chemical douching, external medications (antibiotics, hormonal contraceptive medications), frequent sexual intercourse, leading to disruption of the healthy vaginal flora and overgrowth of yeast cells, resulting in recurring yeast infection.

2. Weak general immune system and unhealthy lifestyle habits

One with underlying medical conditions such as HIV, diabetes, autoimmune conditions with compromised baseline immunity are more predisposed to having recurring vaginal yeast infection. Lifestyle such as high stress environment, excessive alcohol drinking and high glycemic index diet can increase a person's risk of developing recurring vaginal yeast infection.

3. Untreated concurrent vaginal infection

Simultaneous vaginal infection by bacteria such as Gardnerella spp (in the case of bacterial vaginosis), mycoplasma spp, and STDs bacteria (Chlamydia trachomatis, Neisseria gonorrhe, Trichomoniasis etc) is a common reason for vaginal yeast infection to relapse. A diversified vaginal microbiome with less healthy Lactobacillus spp has a weaker natural vaginal layer barrier, predisposing a person's risk to yeast cells colonization and invasion.

4. Fluctuation of reproductive hormones

One may notice that yeast cells may be present during the luteal phase of menstrual cycle (the week just before menstruation). Certain ladies may also notice more vaginal yeast symptoms during their pregnancy. This is due to hormonal changes during the menstrual cycle or pregnancy, resulting in changes in the vaginal bacteria flora composition, and susceptibility to yeast infection.

What should I do if I am concern of recurring vaginal yeast infection?

A large majority of women with abnormal vaginal symptoms including vaginal discharge symptoms tend to self-diagnosed and treat themselves with over-the-counter medications. Unfortunately, studies have shown that only 11% of these women correctly diagnosed their condition. This frequently results in wasting time and money (on ineffective treatment) and delaying recovering from infection.

It is imperative to seek advice from your healthcare providers if you have frequent, recurring abnormal vaginal symptoms. This is to ensure your symptoms are ‘truly’ due to yeast infection rather than other vaginal infective causes. 

Your doctor will obtain a relevant clinical history and offer physical examination of the external genital and vaginal region. In recurring conditions, your doctor may offer vaginal swab tests to obtain a vaginal fluid sample to evaluate for yeast infection or other concurrent bacterial infection. This is paramount in ensuring the right and appropriate treatment is given subsequently. 

What can I do to treat recurring vaginal yeast infection?

Recurring vaginal yeast infection requires longer duration of treatment as short-term antifungal medication may be insufficient to manage the condition. 

• Treatment with antifungal medication for a longer period of time - up to 6 months may be required to suppress the recurring infection.
• Probiotics are encouraged to restore a healthy vaginal flora, compete and displace bad yeast cells from adhering and growing onto vaginal wall.
• Healthy lifestyle with low glycemic index diet can be helpful in managing repeated vaginal yeast infection.
• Those who are sexually active can consider barrier contraception during intercourse with their partner(s) to reduce risk of recurring vaginal yeast infections.
• Screening for concurrent infections for those with recurring symptoms can be beneficial. By eradicating other simultaneous infection(s), the risk of recurring yeast infection can be lowered.

If you’re experiencing recurring vaginal yeast infections, professional care can make a real difference. Our doctors at Dr. Ben Medical Clinic are here to help you find relief and long-term solutions. Book a consultation today to take the first step towards better comfort and health."

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