Which Thrush Treatment Is Best? A Doctor Explains
The normal vaginal mucosa (the inner lining of the vaginal wall) harbours a range of microbes known as vaginal flora. Vaginal thrush or ‘candidiasis’ occurs when the composition of the normal flora is disrupted, resulting in an overgrowth of yeasts. Despite the many types of Candida species, 80-92% of the time thrush is caused by the bacteria Candida albicans.1
There is no single symptom or sign specific to thrush. However it usually does not require any special investigation and is often a clinical diagnosis. While some women with thrush may not have any symptoms, and do not need any treatment at all, some may find their genital area or vulva is itchy or sore, or some may notice a thick, cottage cheese-like vaginal discharge. Sex may be painful or vulva may look red and swollen.
Whichever of these symptoms you experience, unless you have already been diagnosed before, it’s always better to visit your GP and get yourself checked rather than self diagnosing and treating yourself with over the counter medications, because even though thrush is common, it may not always be thrush. It may be some other infection, especially when the discharge is yellowish or malodorous. Your GP may just examine you and come to a clinical diagnosis or will take a swab from your vaginal wall to test for a specific diagnosis.
How is thrush treated?
Thrush, being a fungal infection, is treated with antifungals either orally or topically (intra vaginally). Azoles like fluconazole and miconazole, and polyenes like nystatin are some of the commonly used antifungals for thrush. Azoles and polyenes are two types of antifungals which differ in their mechanism of action. Azoles inhibit the synthesis of ergosterol (the main fungal sterol) and polyenes bind to and interact with sterols present in fungal cell membrane.2 Both these mechanisms result in disruption of the cell membrane of the Candida fungi causing cell death, and thereby reducing the number of fungi in the vagina.
Antifungals are available in various formulations such as oral tablets, and vaginal pessaries or creams. Oral tablets when swallowed are absorbed into the bloodstream through the gut and can affect the whole body, whereas intravaginal preparations act mainly in the vaginal wall and surrounding area, hence systemic effects are minimal.
Vaginal pessaries are pills which needs to be inserted directly into the vagina. These pessaries or creams can be inserted either using an applicator or with fingers. They are advised to be inserted at night as the lying down position will minimise the leakage of drug through the vagina.
Some of these medications need to be prescribed by a doctor and some may even be available to purchase over the counter. Duration of treatment depends on how severe the disease is. In addition, emollients like Vagisan MoistCream, Vagisil Feminine Moisturiser, or even extra virgin olive oil can be applied onto the skin surrounding the vaginal opening, for relief of symptoms such as itching or redness. But keep in mind that they only provide temporary symptomatic relief and do not cure the infection, so they should only be used as adjuncts, and not as substitutes for proper treatment of thrush.
Simple vaginal candidiasis: What are the options?
Most of the time, thrush is just simple and uncomplicated which only needs a short course of treatment. A single dose of fluconazole (Diflucan) 150 mg which is available over the counter, or itraconazole 200 mg twice a day for one day which needs to be prescribed by your GP may be used orally for treatment of simple vaginal candidiasis.3
Alternatively Imidazoles like clotrimazole, econazole, miconazole, or nystatin can be used as topical therapies and clotrimazole (Canesten) pessaries are available over the counter. The number of days it needs to be taken depends on the strength of the pessary or cream; higher the strength, shorter the duration. For example, clotrimazole can be taken as a single pessary of 500 mg stat or 100 mg pessaries can be taken daily for six consecutive nights.
Which is better? Oral vs vaginal therapy
Research claims that the efficacy is the same for oral and vaginal antifungal therapy as there is no significant difference in clinical cure rates in the treatment of uncomplicated disease.4 Also no antifungal is proven to be better than the others as evidence suggests that all azole therapies give a cure rate of over 80% and nystatin preparations give a 70-90% cure rate in uncomplicated thrush.5 So, the decision making on which treatment option to go for depends mainly on personal preference, cost, availability, and side effects, which are detailed below.
Following treatment completion, symptoms should usually resolve by 7-14 days. If it does resolve, no follow up or confirmation of cure is needed. But if it doesn’t, you may need to see your GP to check why there was no response to treatment. It may usually be due to either wrong diagnosis or complicated candidiasis.
When is it considered complicated disease?
Thrush is common and mostly uncomplicated. However if you are pregnant, immunosuppressed, in a high oestrogen state (on combined oral contraceptive pills or Hormone Replacement Therapy) or a diabetic, or have recurrent candida infection (more than four episodes per year) then it is considered complicated vulvovaginal candidiasis. Also, if you are infected with a Candida which is a non-albicans species, that too falls under the category of complicated disease. Treatment varies slightly depending on the condition and usually given for a longer time, hence it’s extremely important to seek medical advice in these instances.
Pregnancy and thrush treatment
Treatment differs a whole lot if you are pregnant. A recent Danish study has reported that pregnant women who took oral fluconazole during pregnancy had a significantly higher risk of miscarriages.6 So oral antifungals are contraindicated in the treatment of thrush in pregnancy. Oral therapy is also avoided even if you have a risk of being pregnant or breastfeeding as some of these antifungals are reported to be excreted in breast milk.
Instead, thrush in pregnancy is treated with intravaginal imidazoles which are usually given for a longer time of about seven days. When inserting the pessary or ovule into the vagina it is advised to use your fingers and to avoid using the applicator in pregnancy to avoid damage to the cervix (neck of the womb).
Do different thrush treatments have different side effects?
Oral antifungals like fluconazole, which are commonly used, are generally well tolerated but sometimes may cause nausea, vomiting, diarrhoea, abdominal pain, or headaches. Intravaginal drugs on the other hand may cause local irritation in the vagina, increasing existing symptoms such as itching and soreness. This irritation is worse when a pessary or ovule with a higher strength is used. Some pessaries and ovules like miconazole are known to damage latex condoms and diaphragms leading to contraception failure. Thus you need to make sure to use an alternative contraceptive method while on such treatment.
Are there any alternative treatment options?
Apart from these medications, many alternative therapies are currently in practice in the treatment of thrush. These include inserting yoghurt dipped tampons, garlic cloves, or boric acid suppositories into the vagina, applying tea tree oil, aloe vera or apple cider vinegar in the genital area, or adding yoghurt, baking soda or coconut oil to the diet.
Even though several studies have shown supportive results with some of these home remedies, well controlled trials with confirmatory evidence are still lacking in this field, so the efficacy and safety of these therapies are not yet scientifically proven. On top of that, some of these ingredients may cause allergy or cause vaginal irritation when inserted, worsening the condition. Douching and cleaning the vagina with soap products, and using vaginal sprays, further disrupts the normal flora within the vagina and alters the pH, facilitating growth of yeasts.
Being such a common infection, thrush affects most females at least once during their lives and approximately half of them will experience a recurrence during their lifetime.7 While you may already be familiar with thrush treatment and your options, if your thrush keeps coming back it is best to visit your doctor to get tested for any underlying conditions.
- BASHH, United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis, Clinical Effectiveness Group, British Association of Sexual Health and HIV, 2007.
- M. A. Ghannoum and B. R. Louis, ‘Antifungal Agents: Mode of Action, Mechanisms of Resistance, and Correlation of These Mechanisms with Bacterial Resistance.’ Clinical Microbiology Reviews, vol. 12, no. 4, 1999, pp. 501–517.
- BASHH, United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis, 2007.
- M. Nurbhai et al., ‘Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush)’, Cochrane Database of Systematic Reviews, 2007. Available from Cochrane Library, (accessed 20 July 2017).
- BASHH, United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis, 2007.
- D. Mølgaard-Nielsen et al., ‘Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth’, JAMA, Vol. 315, no. 1, 2016, p. 58.
- ‘Candidiasis Epidemiology – Vaginosis Self-Study from CDC’, Centers For Disease Control and Prevention [website], 2013, https://www2a.cdc.gov/stdtraining/self-study/vaginitis/candidiasis_candidiasis_epidemiology_vaginosis_self_study_from_cdc.html, (accessed 20 July 2017).