Signs of Vulvovaginal Candidiasis (Yeast Infections)
Frederick R. Jelovsek MD
Many reproductive age women have experienced vulvovaginal candidiasis or "yeast" infections in their lifetime. However candida species of yeast can also exist in the vagina without causing symptoms and can be found in up to 15% of asymptomatic women. Yeast symptoms of itching and burning often overlap with other conditions such as allergic or irritant vulvitis that we have written about in the past. Then what exactly are the signs and symptoms of yeast vulvovaginitis and how reliable are they to use alone, without any cultures or microscopic exams, to make a diagnosis on which to begin treatment?
Recent Research
A recent article, Eckert LO, et. al: Vulvovaginal candidiasis: Clinical manifestations, risk factors, management algorithm. Obstet Gynecol 1998; 92:757-65, looked at this diagnosis problem in 774 women coming to a an STD clinic, but not ones who had been specifically referred for yeast infections as have previous studies on this subject. They collected a thorough set of symptoms and physical signs along with a measurement of vaginal pH, microscopic exam of the discharge (for yeast, trichomonas and bacterial laden vaginal cells) as well as a microscopic exam of the cervical mucous to detect inflammatory (white blood) cells. They also performed vaginal secretion cultures for candida species, trichomonas, and mycoplasma and cervical cultures for gonorrhea and chlamydia
In this group of women who had positive cultures for candida albicans (remember some women have positive cultures but no symptoms) signs of vulvar swelling, cracked skin fissures, a reddened vulva or sores from scratching and a thick, curdy vaginal discharge were infrequent. When the women had their symptoms and findings categorized by whether the culture was positive or negative and whether the microscopic wet-prep was positive or negative, the frequencies in the different groups were interesting.
Symptoms and Signs by Test Results
| Symptom/ Sign | Culture negative wet-mount negative (presumably not infected) | Culture positive wet-mount negative (uncertain infection) | Culture positive wet-mount positive (presumably has infection) |
|---|---|---|---|
| Symptoms | |||
| Chief complaint of vulvar itching or burning |
8% | 13% | 38% |
| vulvar swelling | 10% | 22% | 25% |
| white discharge | 63% | 62% | 68% |
| yellow discharge | 23% | 26% | 22% |
| Examination findings | |||
| vulvar swelling/edema | 2% | 11% | 22% |
| vulvar redness | 21% | 32% | 72% |
| thick curdy discharge (exam) | 1% | 3% | 28% |
From a women's point of view, this means that you can easily have a yeast infection without having burning and itching of the vulvovaginal area. Also though, you can't tell by the color or even presence of a discharge what kind of infection you have.
From the doctor's point of view (exam), vulvar redness is present 3/4's of the time, but not always. A thick, curdy (cottage cheese) vaginal discharge which we think is classic for candida infection, is only present about 30% of the time.
These authors also looked at whether other factors were associated with a higher incidence of positive yeast cultures. They found that recent antibiotic use, condom use, a past history of gonorrhea infection (don't ask me why) and not having had any previous pregnancies was associated with a higher incidence of positive cultures. Interestingly, they also found that there was no higher incidence of positive cultures:
- by use of oral contraceptives
- with absent lactobacillus (the normal vaginal bacteria)
- by symptoms starting in the last half of the menstrual cycle
(luteal phase when progesterone is present)
Conclusions
Using all of this data, these authors offered a management strategy for doctors. A microscopic wet mount test should be performed on all women who have symptoms or who, on exam, have findings of vulvar redness or swelling or a thick curdy discharge on speculum exam. If the wet mount test is positive for yeast, treatment should be started ( this is usually how doctors do it now). If the wet mount is negative, a culture should be performed if any physical exam signs are positive but the woman has no symptoms, or, if there are no positive exam signs but a woman has multiple symptoms. If the culture is positive, treatment is begun.
For a woman to attempt self-treatment without a doctor's exam, if you have a main problem of vulvar itching and/or burning, there is about a 50% chance that a vaginal culture would be positive for yeast. You would save a doctor's visit by self-treating but if the problem does not go away or recurs within a week of finishing the over-the-counter, anti-yeast medication, you should see the doctor to be sure of the diagnosis or a least start looking for other causes of vulvar irritation.
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