Candidiasis

One of the most common reasons women seek health care is vaginitis. Although it is often assumed that it is due to a yeast infection, only 33% of these women will have vulvovaginal candidiasis (VVC).

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VVC encompasses a broad range of issues, ranging from those who have colonization of yeast but are asymptomatic, to those who have frequent, recurrent and symptomatic episodes. Estimates have been that 75% of all women will have at least one VVC infection in their life, 45% will have multiple episodes, and 5 to 8% will have recurrent (RVVC) episodes which is defined as four or more episodes within one year. (1)

Microbiology

Studies throughout the world have shown that Candida albicans is the most common cause of VVC and is the organism identified in 85 to 90% of positive vaginal yeast cultures. However, there are infections with nonalbicans species--such as C glabrata, C tropicallis, and C krusei that are becoming more prevalent in the US. Of the non-albicans species, Candida glabrata is the most common. The number of VVC cases that are due to nonalbicans species is increasing and rose from 9.9% in 1988 to 17.2% in 1995. (2) It is thought that this increase is due at least in part to the increased use of over-the-counter treatments/medications and that nonalbicans species are becoming less and less susceptible to these agents. (3)

Evaluation

A diagnosis of VVC is made by a combination of history, clinical examination, potassium hydroxide preparation and if necessary, a culture. A history that is consistent with VVC includes itching, burning, vaginal discharge that is thick and white, dyspareunia and external dysuria.

The first step in the physical evaluation of a patient suspected of having vulvovaginitis is to determine if she has vulvitis and/or vaginitis. Some women may have vulvar hyperplasia, vestibulitis, genital ulcerations, lichen sclerosis or other dermatitis conditions. A thorough examination of the external genitalia involves looking for erythema, hypopigmentation, hyperpigmentation, fissures, vesicles, ulcerations, thinning and thickening. A woman with VVC will often have vulvar and vaginal erythema, edema and excoriation. A thick white discharge may be present, but many women with VVC do not have a discharge, or have a discharge that is not the typical thick and white characteristic.

The diagnosis can often be made in the office by using 10% KOH and microscopy that demonstrates blastospores or pseudohyphae. An underutilized tool is pH paper. A vaginal pH of less than 4.5 helps to exclude bacterial vaginosis, trichomonis, atrophic, vaginitis or a mixed bacterial/yeast infection. A vaginal culture may help to establish that yeast is in fact present for symptomatic women with negative microscopic findings, and to identify the genus and species.

Prevention Concepts

Preventing infections is almost always preferred rather than treating them. Here are some simple strategies:

* Tight clothing can predispose the wearer to candidiasis. (4)

* Women who wear panty hose have about three times more yeast vaginitis infections than non-wearers. (5)

* Safer sex may be helpful in preventing even infections not clearly considered to be sexually transmitted such as yeast and bacterial vaginosis.

* Support a healthy vaginal ecosystem and immune system by having a generally whole foods diet and very little to no sugar and refined carbohydrates.

* 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 maintaining a normal pH and using condoms until treatment regimen is complete to prevent recurrence.

Overview of Alternative Treatments

An important aspect of treating vaginal infections is looking at the problem more holistically and systemically rather than just finding drug alternatives to killing unwanted organisms. To this end, we try to improve the vaginal immune system, support the whole immune system, 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, also curbing the population and overgrowth of the offending organism. Although this approach sounds basic and logical, it is radically different from the conventional approach which is essentially to kill the overgrowth of the causative organism. Although in severe acute cases, pharmaceutical antifungals may ultimately be necessary, there is evidence that the organisms are becoming resistant to overuse of these products and newer and stronger ones continually need to be developed in order to deal with these resistant strains. So, even when the pharmaceutical 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.

Perhaps no other concept is as important as the health of the ecosystem of the vagina. It is a variable state throughout a woman's lifetime, but nothing is more key to this ecosystem than Lactobacillus.

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.

Nutrition

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 is particularly important in preventing candida vaginitis. In general, a well balanced whole foods diet that is low in fat, sugars, refined foods and alcohol is optimal in preventing all infections. Some women who have severe stubborn cases of chronic candida vaginitis may benefit from more strict diets that avoid fermented foods. These "anti-candida" diets can be rigorous and stressful and most of the time are not necessary.

Botanicals

Garlic (Allium sativum)

Garlic extracts have been shown to inhibit the growth of Candida albicans by blockage of lipid production which thereby inhibits growth. (6) The major growth inhibitory component in garlic extract is allicin and garlic products that have the highest amount of allicin would be the most desireable. Garlic is diverse in its uses for vaginitis because it is both antibacterial and antifungal. (7,8) 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 like a tampon. "Garlic tampons" or garlic capsules can be inserted intravaginally in the morning and then lactobacillus capsules can be inserted in the evening 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. (9) 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.

Additional Treatments

Lactobacillus

Although we often think of only Lactobacillus acidophilus, several species of Lactobacillus populate the vagina. The predominant species of Lactobacillus isolated from the vagina of healthy women remains controversial. 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. (10)

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 lactobacili 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. (11) 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. (12) 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.

Boric Acid

The most successful natural treatment for VVC that I've encountered are boric acid suppositories. Several studies confirm its success, ranging from 64% to 98% effective. (13-15) Although regimens may vary, the most effective in women with chronic, persistent VVC was using a 600 mg capsule vaginally, twice daily for 2 and up to 4 weeks. The only down side I have observed is that if the tissue has been irritated enough by the infection, the boric acid leaks onto the vulva as the capsule melts, then passes over this tissue and burning can occur. 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

Arden's Powder

A colleague of mine has been using a product called Arden's vaginal douche powder for over 20 years. She attributes its antifungal properties to the essential oils of eucalyptus, thyme and boric acid powder. The menthol crystals in the oils provide quick relief from itching and burning even before the infection is cleared. Although I have not been a strong proponent of douching, this old-fashioned approach can most likely be used safely under low pressure.

Mix 1 tsp of Arden's Powder in 1 pint of warm water. Two applications daily for the first two days, then reduce to one application daily for 5 more days. Avoid during menstrual period or during pregnancy.

Sample Natural Treatment Plan for Yeast Vaginitis

Acute:

Avoid sugars and refined carbohydrates, alcohol.

Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus species capsules, 2-4 billion 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 species capsules, 4-8 billion capsules per day.

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.

Prophylaxis:

Avoid sugars, refined carbohydrates, alcohol, fermented foods.

Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus species, 2 billion daily.

Garlic capsules: 1 cap daily by mouth.

Boric acid powder capsules: Insert 1 capsule once daily at bedtime, during menstruation only for 4 consecutive months.

During pregnancy:

Avoid sugars, refined carbohydrates, alcohol, fermented foods.

Eat 8 oz. Acidophilus Yogurt daily or take Lactobacillus species capsules, 2-4 billion daily.

Garlic capsules; 1 cap daily by mouth.

Avoid boric acid suppositories, herbal suppositories.

Principles of Treatment

The main concepts of managing VVC are to be certain of your diagnosis, manage other influences and be creative and persistent when what you are doing is not providing relief or the patient has recurrences. Remember that VVC is frequently misdiagnosed by both patients and practitioners. Taking shortcuts in history, physical exam and testing can result in misdiagnosis, unnecessary treatments and delays in effective treatment. Most cases of VVC will be very effectively treated with natural methods. For those unusual cases that are not, there are various oral and vaginal regimens including butoconazole cream, clotrimazole cream or vaginal tablet, miconazole cream or suppository, terconazole cream or suppository, fluconazole oral, and nystatin vaginal tablets. Treatment options for non-albicans candida infections include more aggressive fluconazole and terconazole regimens, flucytosine vaginally, and boric acid vaginal capsules.

VVC is a condition that may seem trivial to many, but for some, the discomfort, the chronicity, and the health care costs incurred are far more than trivial. The practitioner who is methodical, arrives at an accurate diagnosis, offers empathy and intellect in treatment, will provide the best care to the most patients.

References

1. Foxman B, Barlow R, D'Arcy H, Gilespie B, Sobel J. Candida vaginitis: self-reported incidence and associated costs. Sex Transm Dis 2000;27(4):230-235.

2. Spinillo A, Capuzzo E, Gulminetti R, et al. Prevalence of and risk factors for fungal vaginitis caused by non-albicans species. Am J Obstet Gynecol 1997;176:138-141.

3. Odds F, Resistance of yeasts to azole-derivative antifungals. J Antimicrob Chemother. 1993;31:463-471.

4. Elegbe I, Botu M. A Preliminary Study of Dressing Patterns and Incidence of Candidiasis. Am J Public Health 1982; 72: 176-177.

5. Heidrich F, Berg A, Bergman J. Clothing Factors and Vaginitis. J Family Practice. 1984; 19 (4): 491-494.

6. Adetumbi M, Javor G, Lau B. Allium sativum (Garlic) Inhibits Lipid Synthesis by Candida albicans. Antimicrobial Agents and Chemotherapy. 1986; 30(3): 499-501.

7. Moore G, Atkins R. The fungicidal and fungistatic effects of an aqueous garlic extract on medically important yeast-like fungi. Mycologia, 1977. 15: 466-468.

8. Cavallito C, Bailey J. Allicin, the antibacterial principle of Allium sativum. Isolation, physical properties and antibacterial action. J Am Chem Soc 1944; 66: 1950-1951.

9. Amin AH, Subbaiah TV, Abbasi KM. Berberine sulfate: antimicrobial activity, bioassay, and mode of action. Canadian J Microbiology. 1969; 15: 1067-1076

10. Chan RCY, Bruce AW, Reid G. Adherence of cervical, vaginal and distal urethral normal microbial flora to human uroepithelial cells and the inhibition of adherence of gram-negative uropathogens by competitive exclusion. J Urol 1984; 131: 596-601.

11. Hilton E, Isenberg H, Alperstein P, France K, Borenstein M. Ingestion of Yogurt Containing Lactobacillus acidophilus as Prophylaxis for Candidal Vaginitis. Annals of Internal Med. 1992; 116: 353-357.

12. Hilton E, Rindos P, Isenberg H. Lactobacillus GG Vaginal Suppositories and Vaginitis. J Clinical Microbiology. 1995; 33 (5): 1433.

13. Keller Van Slyke K, Michel V, Rein M. Treatment of vulvovaginal candidiasis with boric acid powder. Am J Ob/Gyn 1981;141:145-148.

14. Jovanovic R, Congema E, Nguyen H. Antifungal versus boric acid for treating chronic mycotic vulvovaginitis. Journal of Reproductive Medicine 1991;36(8):593-597.

15. Sobel J. Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: Use of topical boric acid and fulcytosine. Am J Ob/Gyn 2003;189:1297-1300.

by Tori Hudson, ND

Dr. Hudson is Professor, NCNM; clinical professor, Bastyr U/SCNM; Medical Director, A Woman's Time

2067 N.W. Lovejoy * Portland, Oregon 97209 USA

503-222-2322 * womanstime@aol.com

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