Tools for Practice Outils pour la pratique

#179 Recurrent Vulvovaginal Candidiasis: Can the yeast be beat?

What is the most effective management for women with recurrent vulvovaginal candidiasis (four or more episodes within one year)?

Prophylaxis with six months of azole therapy (like fluconazole) will result in relapse in 9-19% of women compared to 50-64% on placebo (one fewer woman would relapse for every 2-4 treated). Efficacy, however, declines after therapy cessation and clinical cure remains elusive. Limited evidence suggests women may prefer episodic over maintenance therapy.  

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • Two double blind, Randomized Controlled Trials (RCTs) of 3731 and 64 women2 with symptoms and culture confirmed recurrent vulvovaginitis, compared fluconazole  150 mg PO weekly for six months (after initial fluconazole 150 mg PO every 72 hours for 3 daysversus placebo: 
    • Significant difference in clinical relapse rate: 
      • Following six months treatment:1,2 9-19% versus 50-64%, Number Needed to Treat (NNT)=2-4.  
      • 12 month follow-up:1 57% versus 78%, NNT=5.  
        • Smaller study: No significant difference. 
        • No increase in resistance.1,2 
    • Adverse events: 
      • Mild elevation of liver enzymes in one patient, did not require discontinuation.1 
    • Limitations: Analysis only included compliant women.1 
  • Two RCTs examined monthly itraconazole 400 mg PO (114 women)3 or clotrimazole 500 mg vaginal suppository (62 women)4 versus placebo for six months:  
    • Significant difference in clinical relapse rate: 30-36% versus 64-79%, NNT=3-4.  
    • No longer significant at 12 month follow-up.3,4  
  • One observational study, 136 women, individualized decreasing dose (200 mg fluconazole three times/week, weekly x 2 months, biweekly x 4 months, then monthly x 6 months) based on clinical symptoms:5 
    • Clinical relapse during 12 months treatment: 30%. 
    • 18 month follow-up: 45%. 
  • Studies of alternative therapies such as probiotics or homeopathy, are poor quality, and/or with mixed results.6-8 
  • Limited evidence suggests no significant difference between different azoles in Candida albicans acute or recurrent vulvovaginitis.9,10 
  • Candida albicans is responsible for 90% of vulvovaginal candidiasisfollowed by Candida glabrata, which is azole-resistant.11 
  • One small trial (54 participants) demonstrated that treating male partner with antifungals does not reduce relapse rate.12 
  • A randomized cross-over trial of 23 women reported 74versus 14% prefer to treat each episode empirically versus maintenance therapy.13 

Latest Tools for Practice
Derniers outils pour la pratique

#369 Remind me, do medications that target brain amyloid improve my dementia?

Are amyloid-targeting monoclonal antibodies safe and effective for mild cognitive impairment or Alzheimer’s dementia?
Read Lire 0.25 credits available Crédits disponibles

#368 Sodium Restriction in Heart Failure: Beneficial or pouring salt in the wound?

Does sodium restriction improve outcomes in patients with chronic heart failure?
Read Lire 0.25 credits available Crédits disponibles

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Mathieos Belayneh BMSc
  • Christina Korownyk MD CCFP

1. Sobel JD, Wiesenfeld HC, Martens M, et al. N Engl J Med. 2004; 351(9):876-83.

2. Bolouri F, Tabrizi NM, Tanha FD, et al. IJPR. 2009; 8(4):307-13.

3. Spinillo A, Colonna L, Piazzi G, et al. J Reprod Med. 1997; 42(2):83-7.

4. Roth AC, Milsom I, Forssman L, Wåhlén P. Genitourin Med. 1990; 66(5):357-60.

5. Donders G, Bellen G, Byttebier G, et al. Am J Obstet Gynecol. 2008; 199(6):613.e1-9.

6. Falagas ME, Betsi GI, Athanasiou S. J Antimicrob Chemother. 2006; 58(2):266-72.

7. Kumari A, Bishier MP, Naito Y, et al. J Biol Regul Homeost Agents. 2011; 25(4):543-51.

8. Witt A, Kaufmann U, Bitschnau M, et al. BJOG. 2009; 116(11):1499-505.

9. Pitsouni E, Iavazzo C, Falagas ME. Am J Obstet Gynecol. 2008; 198(2):153-60.

10. Fong IW. Genitourin Med. 1992 Dec; 68(6):374-7.

11. Sobel JD. Am J Obstet Gynecol. 2016; 214(1):15-21.

12. Fong IW. Genitourin Med. 1992 Jun; 68(3):174-6.

13. Fong IW.  Genitourin Med. 1994 Apr; 70(2):124-6.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.