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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Woman to Woman Woman to Woman

The Itch That Won't Go Away: How To Deal With Recurrent Vaginal Infections

January 14, 2013

By Alice Y. Chang M.D.

Harvard Medical School

In one of my favorite "Sex and the City" episodes, conservative Charlotte finds out that her vagina is "depressed." Her diagnosis is made when she gets a second opinion about symptoms of itching and discomfort that failed to improve after yeast-infection treatment. In the real world, while there is no antidepressant treatment for an itchy vagina, recurrent vaginal itching and discomfort is not uncommon. Most women will experience vaginitis — itching, burning or discomfort with or without vaginal discharge — at some point in their lives.

If you find that vaginitis treatment doesn't work or your symptoms recur, there are three questions to ask:

  1. Do you have the right diagnosis?
  2. Should you change your treatment strategy?
  3. Is something else making you prone to infections?

Confirm Your Diagnosis

Women can treat themselves for a yeast infection without a prescription. But if the symptoms do not go away or come back quickly, make an appointment with your health care professional to make sure you don't have another type of infection. Resist the temptation to get treated over the phone. Although you may think you are just having a recurrence of the same infection, you could easily have another infection that requires a different treatment. The most common cause of vaginitis is actually Gardnerella or bacterial vaginosis, not yeast. Trichomonas, a parasite, is another cause that is considered sexually transmitted. Finally, you may not have an infection but something else. The more common noninfectious cause for vaginitis in older women is atrophic vaginitis. As estrogen levels fall before during and after menopause, the lining of the vagina can become irritated, creating discomfort and pain.

Since it is normal for bacteria and yeast to be found in the vagina, their presence in vaginal secretions does not always mean that a woman has an infection. For example, vaginal fluid samples from women without symptoms of vaginitis reveals the common yeast Candida albicans up to 80 percent of the time. So if it is normal to find bacteria and yeast in the vagina, how do you know if you have an infection? This is where your health care professional comes in. She or he will evaluate your symptoms in conjunction with some simple tests in the office. Your health care professional can observe the color and odor of the discharge, check the acidity of the secretions, and look at a sample under the microscope to see if there are white blood cells along with bacteria or fungi. Because this is not an exact science that uses one specific test, on your own you might treat for yeast when the problem is bacterial, or for a bacterial infection instead of yeast.

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Alternative Ways To Treat A Difficult Infection

After your diagnosis is confirmed, you will want to sort out whether you need a longer course of treatment or a different treatment. If your symptoms seem to improve with the first treatment, you might just need to take the medicine for a longer period of time. If your symptoms never really improved, a different medication might be necessary. There is also a more uncommon type of fungus that can cause a yeast infection and tends to be resistant to the standard agents used to treat the more common type of yeast infection. To make this diagnosis, a swab from the vagina is sent to the lab for a special culture.

For women with yeast infections that come back more than three times a year, you might talk to your health-care provider about boric acid capsules or yogurt containing Lactobacillus acidophilus. Studies have shown that using boric-acid capsules in the vagina or eating yogurt with Lactobacillus acidophilus cultures on a daily basis can help to prevent recurrent yeast infections.

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Why You May Be More Prone To Infections

Hormonal changes, antibiotics and irritants (douching) can change the acidity and bacterial environment in the vagina. Tight-fitting clothes, synthetic underwear, or increased sexual activity can also increase the frequency of vaginitis. Finally, it is important to check for other diseases that affect your immune system and can make you more susceptible to infections — diabetes, lupus, thyroid disease and AIDS.

Hormonal changes may occur as part of the perimenopause or may be related to birth control pills you may be taking. For persistent or recurrent symptoms of vaginitis during perimenopause, starting a birth control pill may improve the situation. For women on an oral contraceptive, changing the formulation or dose of ingredients may be one answer.

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Be Your Own Health Advocate

An isolated incident of vaginitis is very different from symptoms that persist or recur often. Multiple urgent-care visits to different practitioners may address each current discomfort without addressing the underlying cause. Take the time and effort to make an appointment with your own doctor to fully explore why this is happening again or why it won't go away. Finally, if you are not already seeing a gynecologist, a referral to one can help you to get the right diagnosis and treatment plan.

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Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.

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