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Recurrent vulvovaginal candidiasis

BMJ 2020; 369 doi: (Published 08 June 2020) Cite this as: BMJ 2020;369:m1995
  1. Annabel Lines, medical student1,
  2. Inna Vardi-Flynn, general practitioner with special interest in gynaecology2,
  3. Clare Searle, general practitioner with special interest in gynaecology2
  1. 1Brighton & Sussex Medical School (BSMS), University of Sussex, Brighton BN1 9PX, UK
  2. 2Bridgewater Surgeries, Watford WD18 7QR, UK
  1. Correspondence to: C Searle clare.searle{at}

What you need to know

  • If symptoms of recurrent vulvovaginal candidiasis occur, offer a full examination and laboratory tests as other diagnoses such as bacterial vaginosis, sexually transmitted infections, and dermatitis are common

  • Consider testing for non-albicans species, which may be more effectively treated with nystatin

  • Common predisposing factors and triggers include recent antibiotic use, higher oestrogen states, diabetes, vaginal douching, and sexual activity

A 22 year old woman asks your advice for treating recurrent thrush. She has self managed with over-the-counter treatments eight times in the past six months. She is frustrated and wants to know why it keeps coming back.

Recurrent vulvovaginal candidiasis (RVVC) is a common problem, with an estimated prevalence of 9% in women aged 25-34 years.1 In this article we offer an approach to a safe and effective assessment of a woman presenting in primary care with symptoms of RVVC. We highlight key points from the recently updated British Association of Sexual Health and HIV (BASHH) guideline2 combined with tips from our clinical experience as general practitioners with a special interest in women’s health.

Initial assessment

What are the symptoms of recurrent vulvovaginal candidiasis?

Typical symptoms of RVVC are vulval itching and a non-offensive vaginal discharge. Other common symptoms include soreness, superficial dyspareunia, and a cyclical pattern of symptoms.2 Although a curd-like discharge is typical, discharge can be thin or absent altogether. A green or yellow discharge, or one with an offensive odour, may indicate other causes of infection.

What else should you cover in the history?

Ask if the patient has a history of skin problems such as psoriasis or eczema. Does she have poorly controlled diabetes or symptoms of undiagnosed diabetes? Does she have any medical conditions or take any medications that might cause immunosuppression? Patients are often keen to explore any underlying causes or contributing factors, to help avoid further recurrences. These are listed in box 1.

Box 1

Causes and triggers for recurrent vulvovaginal candidiasis (RVVC)

  • Antibiotics—Vulvovaginal candidiasis occurs …

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