Hi! My name is Tori, and I am a doctor of physical therapy who specializes in pelvic
dysfunction which means I treat things that can go wrong around the pelvis.
Today I want to cover a requested topic—how to treat recurrent yeast infections. First
of all, thank you so much for requesting. I am so honored to be doing request videos
and it really means a lot to me, so thank you. Secondly, know that medical treatment
of yeast infections is outside of my scope of practice, as I cannot prescribe medication.
But I can share how I would treat recurrent yeast infections based on what I’ve seen
work for women that I treat in the clinic, and what I’ve learned from my research.
Because this video is concerning recurrent yeast infections, I want to dive straight
into the less obvious causes and treatments of these recurrent infections, as it has been
my experience that women who have recurrent infections are usually already aware of things
like antibiotics and spermicide causing yeast infections, and tend to have already implemented
the more “common” or “popular” (for lack of a better word) lifestyle changes that
can sometimes help, like replacing synthetic underwear with cotton underwear, eliminating
douching and scented feminine products, avoiding tight-fitting clothing, and things like this.
I will outline the more common causes of yeast infections, lifestyle changes, and why those
lifestyle changes can be helpful in the description below, just in case any of that information
is helpful to you.
So then, I will start by talking more about yeast and the vaginal environment in general,
then propose what I would consider to be the most important questions when it comes to
navigating recurrent yeast infections, and end by taking you down some potential treatment
pathways. Timestamps and links to all the studies I mention will be in the description
below, and…
Last thing I want to mention: if you are working through what you THINK are recurrent yeast
infections, but you don’t have that telltale white, thick, clumpy vaginal discharge or
that kind of creamy film in or around your vagina, rule out Lichen Sclerosus. Lichen
Sclerosus is an inflammatory skin condition that affects the genital skin and it can sometimes
manifest in extreme vaginal itchiness and burning, which can be misdiagnosed—especially
if you are diagnosing yourself—as a yeast infection. If this sounds like it could be
you, follow-up with a gynecologist, get the affected tissue biopsied, and rule out this
diagnosis.
Alright. Let’s begin by talking more about yeast and vaginas.
First of all, recall that—much like your gut—your vaginal environment is full of
microorganisms that play different roles in keeping you healthy. This collection of microorganisms
is often called the “vaginal flora” or the vaginal “microbiota.” Secondly, recall
that yeast is a fungus, not a bacteria, which is why antifungals, not antibiotics, are prescribed
to treat yeast infections. More specifically, yeast infections are caused by different species
of Candida—a species of yeast that is found not only in humans, but also in lots of animals,
and can exist in our vaginal flora without causing us any harm.
To quote this 2016 review article:
Species from genus Candida have a wide distribution in nature and can be found in humans, domestic
and wild animals as well as in diverse environments including hospitals. These yeasts belong to
the normal flora of humans and can colonize the mucosal surfaces of the genital (which
is what we’re talking about, but also), urinary, respiratory and gastrointestinal
tracts, as well as oral cavity, nails, scalp and skin. However, Candida species can be
commensal organisms—meaning they benefit from living in us, but do not help or hurt
us—or transform a symptomless colonization into an infection. Thus, these species are
characterized as opportunistic and can change from harmless to pathogenic—or hurtful—upon
variation of the host conditions—aka upon variation of what’s going on inside of us,
the human host.
So most women, if not all women, will carry some type of Candida in their vaginal flora
at some point during their lives, but will have no yeast infection. For example, this
2004 study looked at the vaginal flora of 1,248 women with no symptoms of a yeast infection
at baseline, 4 months, 8 months, and 12 months time. As it turns out, 70% of women were colonized
by vaginal yeast at one or more of those visits.
So it stands to reason then, that there must be a balance of Candida and vaginal defense
mechanisms of some sort that allow the Candida to remain “commensal,” aka that allow
the Candida to live in the vagina without causing harm to the human host in the form
of a yeast infection.
It is the other microorganisms living the in vagina that defend against Candida overpopulation,
aka a yeast infection. Calling back to that 2016 review article, it is specifically a
kind of bacteria called Lactobacilli that are the primary defense against Candida.
Lactobacilli help to keep Candida under control by: “competing with Candida cells for adhesion
sites, such as epithelial (or skin!) receptors, to which Lactobacillus has higher affinity”—which
just means that Lactobacillus is more likely to adhere to the vaginal skin than Candida.
Lactobacilli “secrete biosurfactants that physically decrease Candida binding.” And,
“most Lactobacillus strains release hydrogen peroxide (H2O2) and fatty acids that inhibit
Candida overgrowth.” So lactobacilli are pretty awesome bacteria that live naturally
in our vaginas and help fight against yeast infections and keep a balanced vaginal environment!
So then, when managing recurrent yeast infections, one of the major questions in my mind is—what
is changing in the vaginal environment that is allowing Candida to overpopulate and cause
an infection?
Another super important piece of the puzzle to consider, is that there are different species
of Candida that can live in the vagina, which means there are different species of Candida
that can cause a yeast infection. In fact, while some infections are caused by one species
of yeast, others can be caused by two or more species.
The most common species identified in women with vaginal yeast infections is Candida Albicans.
(al-bee-cans) In fact, Candida albicans is so common, that within the scientific community,
NCAC—non Candida albicans Candida—is a common acronym used to describe other species
of Candida.
The reason this is worth talking about, is because Candida albicans responds really well
to a certain type of antifungals—azoles. Monistat is a super common over the counter
treatment for yeast infections, and it’s a type of azole. Diflucan, the super common
prescription anti fungal that is often prescribed to treat yeast infections, is also an azole.
And these medications are great if the type of yeast causing your yeast infection is Candida
albicans.
But if you are suffering from recurrent infections, I propose, as does this 2005 study investigating
non Candida albicans Candida and recurrent yeast infections, that the yeast causing your
infections is likely not Candida albicans, which is why typical antifungals have been
ineffective.
With all of this information in mind, I now propose two questions to answer when it comes
to managing recurrent infections: What is changing in my vaginal environment
that is allowing Candida to overpopulate and cause an infection?
What species of Candida is causing the infection? Often, you got to the doctor, and are given
a medication based off of your subjective report without a vaginal swab. Why not get
a swab and find out exactly what kind of Candida is causing your infection, so that you can
move forward with a better-informed treatment plan. If it is Candida albicans causing your
infections over and over again, then the real focus needs to be on answering the first question—what’s
changing your vaginal environment to allow candida albicans to overpopulate? If it isn’t
candida albicans causing your infection, then you likely need a treatment other than an
azole!
Alright, now let’s go down a few different potential treatment pathways together.
Let’s say it isn’t candida albicans that is causing your infection, and the reason
you’ve had recurrent yeast infections is because you’ve been trying to treat them
with an azole. A treatment option that I’ve seen work wonders in the clinic is a combination
of boric acid vaginal suppositories and vaginally inserted probiotics that contain lactobacilli.
The intention with this treatment is twofold: As this 2011 study demonstrates non candida
albicans candida DOES respond to boric acid—it acts as an effective anti-fungal where azoles
do not. And, as we’ve discussed, lactobacilli are
an amazing defense against Candida in general, so why not give the vaginal environment a
boost of lactobacilli during treatment?
In the clinic, I usually see boric acid suppositories inserted vaginally 1x/day for 7-14 days, then
2x/wk for a month or so, paired with a probiotic inserted vaginally around 2-3x/wk while taking
the boric acid.
The strains of lactobacilli that I understand to be very important in vaginal health are
lactobacillus rhamnosus and reuteri — these are the two strains of the bacteria that
you may want in the vaginal probiotic.
Please, please, please speak with your physician before implementing this protocol. Make sure
it is a safe option for you, and that the yeast infections you are treating are caused
by a non candida albicans candida.
The other treatment pathway—you’ve tried boric acid and vaginal probiotics, but you
are still getting infections. Something must be going on in the vaginal environment that
is promoting these infections. One potential cause to consider is hormones.
I want to read another quote from that 2016 review article that speaks to increased yeast
infections during pregnancy, and the relationship that exists between yeast infections and hormone
levels.
“The high incidence of [yeast infections] in pregnancy has been attributed to the increase
of sex hormones secretion in pregnancy. In fact, during pregnancy, [yeast infection]
prevalence is higher in the last trimester, when levels of hormones are more elevated,
even though symptomatic recurrences are common throughout pregnancy. Furthermore, in nonpregnant
women the infection is more incident during the luteal phase of the menstrual cycle, which
is the phase with the highest hormone secretion. Despite being accepted that [yeast infections
have] a hormonal dependency, the mechanisms by which progesterone and estrogens act in
the disease are not fully understood.”
So, there is clearly a relationship between hormone levels and potential yeast infections—hormones
can change the vaginal environment somehow—but we aren’t really sure what that relationship
is.
First question: are you taking oral birth control? Studies dating back to 1995 support
that birth control pills may contribute to current yeast infections.
Second question: do you have an IUD? As it turns out, yeast can adhere to medical devices
like IUDs, and create something called a biofilm—which is essentially a structured community of yeast
that is very strongly attached, in this case, to the IUD. This phenomenon has been studied,
and if there is a biofilm on your IUD, you need to get it removed to stop the recurrent
infections.
Third question: you’re not taking birth control pills, you do not have an IUD—have
you been tracking your symptoms? If not, TRACK YOUR SYMPTOMS AND your cycle! As the 2016
review article pointed out, the luteal phase of your cycle—which happens after ovulation—involves
a big change in hormone levels. Are you symptoms happening in tandem with the luteal phase
of your cycle?
If this is the case, and the boric acid/vaginal probiotic treatment doesn’t work as a vaginal
reset, you can still manage your symptoms via your diet. As we’ve talked about, yeast
is a type of fungus, which means it’s alive. It needs nutrients to survive. If you want
to effectively starve out candida—since you don’t need them in your vaginal flora,
when they’re not causing an infection, remember that they are commensal organisms, not helping
or hurting us—you can. With a sugar-free, grain-free, and dairy-free diet—otherwise
known as the candida protocol.
If you know your symptoms are cyclical, you could pair the candida protocol with the luteal
phase of your cycle—in other words, there would be about 12-14 days per month where
you’d follow the candida protocol.
Let’s say the cause behind your recurrent infections isn’t hormonal at all and you’ve
tried everything I’ve talked about. The last idea I have to offer is trying the candida
protocol for at least 3 months, and pairing it with a probiotic that includes the lactobacilli
strains I mentioned earlier. If it were me, I would commit to 12 weeks, because why not,
and try to starve the candida causing my infections and boost the idea vaginal environment to
fight against candida.
Alright, thank you all so, so much for watching and requesting, I really can’t tell you
how honored I am to be doing request videos! Please, if you found this video helpful, don’t
forget to like it and share it! Feel free to comment anything about this topic, or suggestions
for future content below. I do try really hard to read and respond to all of my comments.
Finally, please subscribe to my channel for more content surrounding pelvic health and
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more love, I promise! And thank you again so, so much for watching. I will see you in
the next video, bye!