When a yeast infection won't go away

Ask Dr. Jen

I’ve had a yeast infection for months and it won’t go away!

- From a lot of people!

This is a common referral to my practice and I get asked a variation on this question a lot on social media. It came up again recently, so I’m going to walk you through how I address this as an expert in the office as I see patients with this exact concern almost daily. Sometimes this question means my patient has had persistent symptoms despite many therapies and other times it means the symptoms go away with therapy, only to return quickly. This post will cover both of these scenarios.

There are four possible diagnoses here, and I am going to walk you through each one. However, before we begin there are several key pieces of information that an expert (, a medical doctor who is board certified in OB/GYN, has done a fellowship in infectious diseases and OB/GYN, who has run a clinic for people with complex vulvar and vaginal conditions for over 25 years, and who sees multiple people with yeast infections every day,) like me knows, and that I want you to know as well.

• A white discharge is not a sign of a yeast infection, and no, it doesn’t matter how chunky it is. This is something someone wrote once in a book and it has been perpetuated. It’s an old doctor’s and an old wive’s tale. People can have awful yeast infections and have no discharge, and they can have tons of white, chunky discharge and have zero symptoms and have a perfectly normal vaginal microbiome. Forget about the white discharge! Really.

• About 50% of people who self diagnose with yeast are incorrect. I know this is hard to hear and it may sound like medical gaslighting, but what I mean here is that what most people have been taught about vaginal discharge and about yeast is incorrect. For example, if you were taught a white, chunky discharge is a sign of a yeast infection, then you might be thinking you have yeast when you don’t. Vulvar itching, meaning on the outside where your clothes touch your skin, is also not typically a sign of yeast, the itching and/or irritation and/or burning (the three common symptoms) are typically vaginal or right at the vaginal opening. So if you have been told your vulvar itching is a classic sign of a yeast infection, you were misinformed. I blame medicine, alternative medicine, and so called “women’s magazines” for spreading incorrect information about yeast.

• Many medical providers diagnose yeast incorrectly. This is unacceptable, but it is a fact that you should know. Some providers just look at the discharge and say, “Yep, that is yeast.” That is about as accurate as flipping a coin. You deserve better. Many providers, myself included, look at vaginal samples under the microscope to diagnose yeast. It looks like the image below. However, most providers don’t learn microscope skills like I and other vaginal experts did, so they can often overcall yeast or miss it altogether. Even in my hands, and I diagnose yeast several times a day this way, I can miss it under the microscope about 30% of the time. So only relying on the microscope isn’t a good idea for most who have not been taught extra skills. It also isn’t a good idea for the situations we are discussing. The gold standard for diagnosing yeast is a culture. If you have a recurrent infection or an infection that you think won’t go away, you absolutely need a culture. Not a DNA test, a culture. If you have been tested for yeast you need to ask, how? It must be a culture.

Candida albicans under the microscope

• Yeast usually produces visible signs of irritation, such as redness and/or swelling. However, this can be very subtle and someone who doesn’t evaluate a lot of vulvas and vaginas can miss it.

• Other symptoms that can be seen with yeast, but can also be caused by other conditions which is part of the complexity, are vaginal dryness and pain with sex.

Okay, let’s look at the four scenarios

1. You do not have yeast, you have a different diagnosis. This is especially likely if your symptoms are on your vulva. Lichen simplex chronicus is a common cause of a vulvar itch so bad that you have to scratch or really need to scratch and are doing your best to keep your hands off. It is an eczema-like condition. Other skin conditions with the same symptoms of yeast are lichen sclerosus, lichen planus, and even genitourinary syndrome of menopause (if you are in menopause and not using vaginal estrogen, yeast infections are stunningly rare). Bacterial vaginosis, a vaginal infection, can also be mistaken for yeast. The way to sort this out is an exam in the office so the exact location of the symptoms and any signs of yeast can be identified. This also allows us to look for signs of menopause and to evaluate for skin conditions. A vaginal culture for yeast must also be performed. If the culture is negative, meaning no yeast, something else other than yeast is causing your symptoms. If you felt better when using yeast medications and so wonder how you can’t really have yeast there are a few explanations. For example, you originally had yeast and the itching from the yeast triggered the itching you now have, but the yeast has since gone. Think of yeast like a match that started the fire, but you don’t treat a fire by focusing on the match. Another possibility is topical yeast medications can be soothing and oral fluconazole may have weak anti-inflammatory properties. And there is also the possibility of a placebo effect. It’s okay if you don’t have yeast, getting the right diagnosis will let you get the right therapy!

2. You have a recurrent yeast infection. Meaning your yeast gets treated and a few weeks later it comes back. Why this happens we are not always sure, it is usually a complex issue related to the vaginal ecosystem. Some people are at higher risk, for example those with diabetes or HIV. In my podcast, Body Stuff, we devoted a whole episode, in the upcoming 2nd season, to yeast so I hope you will listen when that comes out so you can learn more about this. This requires a culture to diagnose. The treatment is suppression with fluconazole (Diflucan). This regimen has been well studied. It consists of taking 2-3 pills over a week and then 1 pill a week for at least 6 months. This controls the yeast and hopefully the ecosystem controls itself. When the regimen is stopped, if the yeast returns, the medication is restarted. Often after 1-2 years of this, people can eventually stop the medication. This regimen is backed by excellent evidence based medicine. It is key to see someone back after they start this therapy if they are not 100% better. I do a phone call at 4 weeks after starting therapy and tell my patients if they are no better then we can switch it to an in person. The reason I do this is 20% of the time people with no symptoms have positive yeast cultures, because yeast is part of the microbiome. So, when doing a culture I don’t know for sure the yeast is the cause. If they have classic signs of yeast in exam, redness and swelling, then I am very confident it is yeast, but at 4 weeks if there are still symptoms then we need to reevaluate. If I started a medication that I know should work, fluconazole every week, and it isn’t working there are now two additional possibilities:

   • The yeast is the cause of the symptoms, but it is resistant, meaning the fluconazole can’t work. The culture will be positive and I will get the lab to run sensitivities, so I know how to treat it. This means we have a resistant yeast scenario (see #3 below).

   • The yeast was never the cause of the symptoms or not causing all of the symptoms. The positive culture was the baseline 20% of yeast in the vagina, not a sign of infection. I will know this if the yeast culture is now negative, yet the symptoms persist. This means we have the scenario described in #1 or #4 and I need to reevaluate for other causes of irritation, itching and/or discharge.

3. You have a resistant yeast infection. Meaning the yeast that you have had has never gone away, because the medication couldn’t work. Some types of yeast are naturally resistant to the oral and the over the counter yeast medications and some yeast develops resistance over time. This also requires a culture to be diagnosed properly. For example, if the culture grows Candida kruseii, we know it cannot be treated with fluconazole, but clotrimazole might work. If the culture shows Candida albicans, the most common cause of a yeast infection, we ask the lab to test for sensitivities, meaning the lab does tests to tell us what medication might work. Once we know, we can design the right therapy.

4. You have a skin condition, as discussed in #1 and you also have a yeast infection. Skin conditions damage the skin barrier, making you more susceptible to yeast. This can sometimes be complicated to sort out, especially as 20% of people have yeast in their vagina at a given time and have no symptoms. Meaning, a positive yeast culture isn’t always an infection, it could just be your friendly neighborhood yeast. A yeast infection is when this normal yeast overgrows and causes symptoms, but a culture can’t tell us if this has happened. If there is vaginally inflammation then that makes yeast more likely as the culprit. If someone has an obvious sign of a skin condition and a positive yeast culture, we usually treat both. If the yeast is sensitive to fluconazole, I would start the weekly therapy as described in #2 so we can keep the yeast away while we work on the skin condition, and how you respond helps determine if one or both of these are causing the symptoms.

And a few more things…

• Diet does not impact yeast infections. There has literally never been any data to suggest otherwise and we have good data that demonstrates there is no link.

• Probiotics have no impact.

• Testing reproductive hormone levels is not indicated.

• Anyone telling you they can fix the “root cause” is full of shit.

• Boric acid does not balance the pH. Boric acid is only used when we have identified yeast that is resistant to pharmaceuticals by doing a culture. Read more about boric acid here.

• Checking for iron deficiency and checking your thyroid levels are a good idea.

• Don’t waste your money on vaginal microbiome testing. Consider these tests to be worthless until the companies actually do studies that show otherwise.

And that is Gunter’s Guide to working through the “Help, I have a yeast infection that won’t go away” scenario. I hope it helps you!

If you want to know more, please check out The Vagina Bible which has a lot of info like this, and more.

I know there will be many questions, and so feel free to post them here, but I am going to do a Yeast AMA (Ask Me Anything) tonight at 7 pm Pacific Time. This is a subscriber only feature. If you are a subscriber you will receive an email about the AMA, as you will for any post, but I will spend an hour answering questions in real time. You can still leave questions after the “live” has expired and I will answer them.