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DocSpot: Thrush

Dear Dr Margaret

I keep getting thrush. It goes away with the treatment, but then comes back again. Why? How can I get rid of it for good? Lots of my friends have the same problem. I’m 17.

You have my sympathy - thrush that keeps coming back (‘recurrent thrush’) is frustrating and distressing. You could try some self-help measures or you might want to discuss a more intensive anti-thrush treatment with your doctor. It’s also worth checking that your symptoms are really being caused by thrush. In answer to your question about why you should keep getting it, there are three theories - the gut theory, the sexual theory and the vaginal relapse theory. Read on to find out more about these and for my full answer to your question.
 

Why do some people keep getting thrush?

We know that thrush is usually caused by a yeast called Candida, but doctors do not fully understand why some people keep having the problem. There are three theories:
 
The ‘gut theory’ says that Candida yeasts lurk in the lower part of the gut ( the rectum). When you use an anti-thrush cream you get rid of thrush from the vulva (the area around the opening of the vagina). According to this theory, you later get a re-infection from your own gut. This theory was very popular in the 1970s but most doctors no longer believe it, because clearing Candida from the gut (by a long course of tablets) does not prevent recurrent thrush.
 
The ‘sexual theory’ says that your partner re-infects you, even though he does not have any symptoms himself. It is true that about 20% of partners of women with recurrent thrush have the same type of yeast in their mouth or on their fingers or genital area - but most do not have any. And scientific studies mainly show that treating a woman’s partner has no effect on the likelihood of the woman having recurrences.
 
The ‘vaginal relapse theory’ is the one believed by most doctors. It seems that treatment does not eliminate the Candida totally. Tiny numbers of the yeast remain. If the situation is right for them - for instance, they like skin that is moist and warm - they slowly multiply until there are enough to cause symptoms again.
 

Self-help measures

It may seem obvious, but it is important to check that you really do have thrush. The fact that it goes away with anti-thrush treatment suggests that it probably is thrush, but it is worth making sure. This means a visit to your GP or local genitourinary clinic for a swab. The swab will be sent to a lab, which will be able to tell whether Candida or similar yeasts are present. Although Candida is the usual cause of thrush, in about 1 person in 20, symptoms are due to a slightly different type of yeast, for which another treatment might be more effective. With recurrent thrush there is an even greater chance that it is an unusual type.
 
It is crucial to make life as difficult as possible for the Candida yeasts, so look at the advice about avoiding vulval irritation in our vulva section.
 

Natural remedies

You might wish to try some natural remedies.
  • Bio (‘live’) yoghurt is often recommended. You gently smear a small amount of yoghurt over the vulva, and also put it inside the vagina. The easiest way to do this is to use a tampon with its applicator. Push the tampon back inside the applicator so you have a space for about a teaspoonful of yoghurt. Then insert the tampon in the usual way, which will push the yoghurt into the top of the vagina. Remove the tampon an hour later.
  • Another possibility is tea tree oil. Dilute 20 drops of tea tree oil in half a cup of water, soak a tampon in this liquid and then insert it into the vagina. Change it as frequently as you would a normal tampon.
  • Buy some 9% acetic acid gel (Aci-Jel) from a pharmacy. It comes with its own applicator.

My problem with yoghurt and tea tree oil is that I have not been able to find any proper scientific studies to show whether or not they work and whether they have any bad side-effects. Therefore I hesitate to recommend them strongly. They might be worth a try, particularly for relieving symptoms in a mild attack. I wouldn’t use them continuously to try to prevent recurrence, but they could be useful if your thrush usually comes before a period. For example, if you tend to get your symptoms on days 21 - 24 of your cycle, you could use one of these remedies starting on day 18. And remember you can get a reaction to a natural remedy as easily as to a cream from the chemist, so stop straight away if that happens.

A yeast-free diet is often suggested. There is no evidence at all that this has any effect, so don’t bother.
 

Possible medical treatment

I have talked to several specialists about drug treatments, and they all agree that if you are having more than four troublesome episodes a year you might consider taking ‘suppressive’ therapy. This usually means taking an anti-thrush tablet, prescribed by your doctor, every day or once a week (depending on which product it is). My view is that taking a prescription drug every day for a condition that is not seriously hazardous to your health is a big decision. Discuss all the pros and cons very carefully with your doctor, and go for it only if your symptoms are really distressing.
 
The specialists also said that they would not usually treat your partner, because they don’t believe in the ‘sexual theory’. But they weren’t absolutely fixed about this, and some said they might do so if a woman had lots of recurrences.
 

Last updated; Wednesday, October 1st 2014


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