Vaginal thrush: not exactly a topic for dinner-table conversation, but something almost every woman will face at some point. It’s one of the most common causes of vulval and / or vaginal itching and discharge, yet it’s often misunderstood – or self-treated without a proper diagnosis having been made.

So let’s clear up the confusion!

In this blog we’ll cover:

• What thrush is
• Who’s most at risk
• Common symptoms
• How doctors diagnose it
• Optimal treatment options (including for recurrent thrush)
• Practical self-care tips
• When it’s time to see your woman’s health GP

What is thrush?

Thrush (or ‘vulvovaginal candidiasis’) is caused by an overgrowth of Candida yeast in the vagina and / or on the vulva. Normally, Candida lives happily alongside healthy vaginal bacteria. But when the balance is disrupted (say, after having antibiotics), yeast can take over and cause annoying symptoms.

A few important clarifications:

• Thrush is not a sexually-transmitted infection, although it can occasionally be passed on during sex
• Finding Candida on a vaginal swab doesn’t always mean infection: many women carry it harmlessly without symptoms
• Thrush is rare before puberty and after menopause (unless you’re using menopausal hormone therapy)

Who’s gets thrush, and why?

Thrush is common: about 40% of pre-menopausal women will have at least one episode.

Precipitating factors include:

• Antibiotics (up to one-third of cases occur after a course of antibiotics)
• High oestrogen states like pregnancy, the combined oral contraceptive pill, or menopausal hormone therapy
• Poorly-controlled diabetes
• Immune suppression (e.g. due to steroids, HIV, or another immune-suppressing medication or condition)
• Vulval skin conditions, such as dermatitis or lichen sclerosus
• Possible lifestyle triggers, such as: tight clothing, synthetic underwear, perfumed soaps, or douches

Sometimes, thrush strikes for no obvious reason at all (which can be even more frustrating!)

Common thrush symptoms

Typical thrush symptoms include:

• Vulval itch, which can be quite intense
• Vulva and / or vaginal burning or stinging, especially when urinating or during sex
• Thick, white discharge (often described as “cottage cheese”)
• Redness, swelling, and soreness of the vulva (the skin around the vagina)

Symptoms are often worse in the lead-up to your period.

But here’s the catch: these symptoms overlap with other conditions, like bacterial vaginosis or dermatitis. This is why seeking a formal diagnosis matters!

Diagnosing thrush

About 1 in 6 women carry Candida in their vagina without any symptoms. Thrush is only diagnosed when there are both symptoms and a vaginal yeast present.

Unfortunately, self-diagnosis is quite unreliable. In one study, two-thirds of women who thought they had thrush actually didn’t: they had other conditions instead.

That’s why you should see your woman’s health GP to confirm the diagnosis. This is especially important if your symptoms are atypical or recurrent. Your GP may:

• Examine the vulva and vagina
• Perform a speculum examination
• Take vaginal swabs to: confirm which Candida species is present; determine its sensitivity to common anti-fungal medications; and to rule out other conditions

Types of thrush

Doctors usually classify thrush as either:

• ‘Uncomplicated thrush’, which: is associated with mild to moderate symptoms; occurs in only infrequent, sporadic episodes; and is caused by Candida albicans
• ‘Complicated thrush’, in which any of the following apply: severe symptoms;  recurrent thrush (i.e. occurs more than 3 times in 12 months); the underlying Candida being a non-albicans species; and / or thrush in women with an underlying condition (such as diabetes, pregnancy, or HIV)

Treatment options

The good news: thrush is usually very treatable!

Treatment of uncomplicated thrush

As outlined above, ‘uncomplicated thrush’: causes only mild / moderate symptoms; occurs only sporadically; and is due to the yeast species Candida albicans.

Treatment includes:

• Topical anti-fungal medications, e.g. clotrimazole cream or pessary, of various strengths. Options range from a one-off dose, to a nightly dose for up to 6 nights. Pessaries tend to work better for vaginal symptoms (e.g. chunky white discharge), while a vulval cream may suffice if all you have are vulval symptoms (e.g. tenderness, and redness of the skin around the vagina). While symptoms generally improve within 1 – 2 days, complete symptom resolution may take up to 2 weeks.
• A one-off 150mg oral fluconazole tablet. If you have only mild symptoms, this may be enough to treat your thrush. If you have moderate symptoms, you may need a second similar tablet, taken 3 days after the first. This may be appropriate when vaginal treatment is less acceptable, or more convenient for you.

Vaginal (clotrimazole) and oral (fluconazole) treatment results in symptomatic relief in approximately 85% of women. All regimens have similar effectiveness, so you can choose between them based on your symptoms, the regimens’ availability, cost, and your own personal preference.

Treatment of complicated (including recurrent) thrush

As outlined above, ‘complicated thrush’: causes severe symptoms (such as vulval fissures); is recurrent (i.e. when there are more than 3 episodes of thrush in 12 months); is due to a non-albicans species of thrush; and / or there is an underlying medical diagnosis, such as pregnancy or poorly-controlled diabetes.

Roughly 1 in 10 women will experience recurrent thrush. It can be particularly frustrating, disruptive, and can impact quality of life.

Treatment may include:

• An extended course of anti-fungal medications: either oral tablets (e.g. 3 doses of 150mg fluconazole, 3 days apart) or longer vaginal treatments (e.g. clotrimazole pessary every night, for up to two weeks)
• Suppressive therapy: ongoing treatment (such as weekly oral fluconazole for six months) to keep symptoms under control
• Combination therapy: oral fluconazole plus vaginal clotrimazole, taken at the same time
• Alternative treatments, such as boric acid pessaries: this is sometimes used in resistant or non-albicans infections
• Investigating underlying causes, such as diabetes, or skin conditions

It’s inadvisable to continue self-treating recurrent or persistent thrush without thorough evaluation by an experienced women’s health GP, such as Maven Centre’s Dr Amy Sinclair-Thomson or Dr Phillippa Wootton.

Approximately 10 – 20% of symptomatic thrush is caused by a non-albicans species of Candida (such as Candida glabrata), which may not respond to standard treatments. Vaginal boric acid pessaries may be needed.

The key message: if thrush keeps coming back, don’t just keep self-treating. See your woman’s health GP for a structured management plan!

What’s the deal with boric acid?

Boric acid pessaries are sometimes used when thrush is resistant to the standard anti-fungals, or is caused by a non-albicans species. They’re not first-line treatment, but can be very effective in select cases. Boric acid treatment should only ever occur under the guidance of a women’s health GP, such as Dr Sinclair-Thomson or Dr Wootton.

Self-care and lifestyle tips

While medication does the heavy lifting, these small changes may help to reduce the risk of recurrent thrush:

• Use gentle, unscented soaps, and avoid douches and perfumed washes
• Wear cotton underwear
• Avoid tight synthetic clothing
• Avoid panty liners and pads when possible
• Avoid bubble baths and scented hygiene products
• If you have diabetes: manage your blood sugar carefully
• If your vulval skin is sore: consider using a barrier ointment or emollient

Despite popular belief, probiotics don’t help to prevent or treat thrush.

When to see your woman’s health GP

Book an appointment with a woman’s health GP if:

• Your symptoms don’t improve with over-the-counter treatment
• You have unusual symptoms, such as smelly vaginal discharge, fever, or pelvic pain
• You have experienced recurrent thrush (more than 3 episodes per year)
• You’re pregnant or breastfeeding
• You have underlying health conditions (e.g. diabetes, immunosuppression)

Conclusion

Thrush is one of those common-but-frustrating conditions: uncomfortable, inconvenient, and often misunderstood. But the good news is that it’s very treatable, and with the right approach, even recurrent cases can be managed.

So if you’re dealing with itching, discharge, or discomfort – and especially if it keeps coming back – don’t just reach for the same old over-the-counter treatment! See your woman’s health GP for an accurate diagnosis and tailored care. Relief really is possible…