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Recurrent Thrush

Candida and Thrush

Candida is one of several types of yeast-like organisms that cause infections in humans. There are a number of different varieties of candida, the commonest being candida albicans which can cause infection in the vagina, mouth and skin. Infection with candida is commonly called ‘thrush’. It is also the organism that plays a part in the development of nappy rash in infants. The organism grows best in warm, dark conditions and in the presence of sugar. Under these circumstances candida changes from small round dormant spores to a branching structure called a mycelium with the ability to invade and irritate tissues.

Candida is a very common organism that we have all had some contact with, and the majority of infections resolve themselves spontaneously. That said, some women experience repeated episodes of vaginal thrush, and there are usually a number of reasons for this (see opposite). In the last few years some doctors and complementary practitioners have put forward the idea that a number of health problems including chronic fatigue can be caused by infection with candida. The evidence for this is not strong.

Top What are the symptoms

This depends on where the infection is. For women, vaginal thrush causes irritation and a thick, white, sticky discharge. This must be differentiated from the normal vaginal moisture that naturally increases at mid-cycle and is not associated with local irritation. Severe infections in women can cause swelling of the genital tissues and a rash can spread out into the groin. In men, soreness or redness of the penis, sometimes with a sticky white discharge, may develop. However, many men and women may carry small amounts of candida in the vagina or on the penis without any ill effects.

Candida is often kept in check by the presence of healthy non-diseasecausing bacteria in both the vagina and the bowel. Surveys reveal that about 20 per cent of the normal population carry candida in the digestive tract without it causing problems. Thrush in the mouth, which mainly affects the ill, elderly or those using steroid inhalers for asthma, produces a very sore mouth and a white sticky deposit on the tongue and elsewhere. A slightly furred tongue without soreness is unlikely to be due to candida. The skin can be infected, too, and this is usually in warm moist areas such as the groin, armpits or under the breasts. A red, sore rash with spreading little red spots or ‘satellites’ at the edge of the rash is the usual appearance.

Top Who gets it

In short, we all do once or twice, but for those women who get repeated attacks of vaginal thrush there are often one or more predisposing factors. They include: • Being pregnant Hormonal changes encourage thrush.

• The combined oral contraceptive pill Those with a high oestrogen content may increase the risk; this is rarely a problem with newer lowdose ones.

• Steroid drugs These, whether taken as tablets or as an inhaler, can encourage the growth of candida.

• Antibiotics By killing off the ‘good’ bacteria, antibiotics make it easier for candida to obtain a foothold.

• Diabetes The increased levels of sugar in diabetes make it easy for the thrush organism to grow.

• Anaemia and lack of iron These can reduce resistance to infection and lead to cracking at the corners of the mouth, making it easy for the infection to get started – one to think of in women with heavy periods.

• Other nutritional deficiencies Lack of zinc, vitamin B and even vitamin A have all been documented as reducing resistance to infection and leading to thrush.

• A poor diet A diet high in sugar and low in protein can probably make matters worse, though there is no direct proof of this.

• Reduced resistance to infection Anything that reduces your resistance to infection from stress, genetic and blood conditions to cancer, can be significant.

• Hormonal disturbances Thyroid, other hormone problems and low blood calcium can all (rarely) lead to episodes of thrush.

Top What causes it

As you can imagine, anyone with one or more of the above predisposing factors is likely to experience thrush at some time. A common situation involves a sexually active woman, possibly on the pill, who may have a mild iron deficiency, and for whom treatment using over-the-counter creams has been only partially successful. Research suggests that, in recurrent cases, candida organisms on the skin or possibly from the bowel provide a source of re-infection. Sometimes this comes from the male partner, and intercourse or use of a tampon may be factors in causing a break in the delicate tissues lining the vagina and allowing infection to develop.

Wearing trousers, tights, and nylon underwear may all promote the conditions that encourage the growth of candida. Local irritation can be aggravated by use of some chemicals found in many toiletries, bath products, soaps and shampoos so it may be necessary to avoid these. Occasionally it appears that some sufferers are actually allergic to or react strongly against candida itself. In these cases, even a minor degree of infection can result in severe symptoms.

There is also evidence that reactions to foods or yeast in the diet may cause a vaginal discharge. This might cause symptoms similar to thrush without candida being present, or the reaction may encourage the growth of candida already present. So, for some, a change to a healthier diet that excludes some foods can help symptoms of thrush.

Top What your doctor can do

Your doctor can do one or more of the following:

• Examine you and take a swab from the vagina to assess the type of infection.

• Prescribe an antifungal treatment as a cream, pessary or tablet by mouth.

• Perform some tests to see why you have thrush. A urine test for diabetes and a blood test for anaemia and iron deficiency would be the most common and useful.

There is a wide choice of different preparations available that your doctor may prescribe. They can be creams, pessaries or tablets and they all have similar success rates. The main choices are:

• Nystatin as cream or pessaries. Once the most popular treatment, now largely replaced by other preparations. It is safe for use in pregnancy. Nystatin can also be given by mouth but as it is not absorbed this is only useful in clearing candida from the bowel. It is very useful for helping clear thrush in the mouth.

• Clotrimazole (Canesten) available as a cream or pessary and often this first-line treatment can be used as a one- or three-day treatment with similar high success rates of over 90 per cent.

• Miconazole (Daktarin) and Econazole (Ecostatin and Gyno-Pevaryl) also available as pessary and cream.

• Fluconazole (Diflucan) is a powerful anti-candida drug which is active by mouth and is highly effective after one single dose of 150mg. It is very effective against Candida albicans but not other types of candida.

• Itraconazole (Sporanox) is another anti-fungal agent which comes in tablet form. Two 100mg tablets twice a day for one day only will usually clear thrush and it has the advantage of being effective against different types of candida, not just albicans. The key point to remember is that all these treatments have a small failure rate and that if one treatment is not successful then another probably will be.

Top What you can do

Many women do not go to their doctor but get treatment themselves from the chemist using a number of over-the-counter preparations. This is acceptable if you are reasonably certain that you do not have any other infection, and provided that your symptoms clear within three or four days. If not, see your doctor or attend a local STD (Sexually Transmitted Disease) clinic. Such clinics are particularly well equipped to identify the type of infection and the best form of treatment. You do not need to be referred by your doctor but can simply ‘drop in’.

It is probably useful for you to know that some 50 per cent of women who think that they have thrush may have a different type of infection, and that the success rate for most standard anti-fungal treatments is 90 per cent. Consequently there will always be a significant number of women whose ‘thrush’ did not clear with the first treatment they try. In cases like these there is no substitute for an internal examination, a swab to identify the type of infection(s), and tests in the laboratory to find which anti-fungal agent is the most effective.

In addition to infection itself, the irritation may be due to some degree of allergy to candida itself, to local irritation from toiletries or occasionally to food allergy. There is no easy way for the sufferer to determine which of these might apply to them without expert assessment, so the advice given below is relevant for all eventualities.

• Avoid wearing restrictive clothing such as trousers, tights and synthetic underwear. Choose natural fabrics such as cotton or silk.

• Shower rather than bath, and do not use perfumed soaps and other toiletries that might come into contact with your tail end. If you do have a bath, do not wash your hair at the same time. CANDIDA AND THRUSH 127

• Dry yourself thoroughly after a bath or swimming.

• Do wash and change your underwear every day.

• When washing your clothes and underwear it may be preferable to use a non-biological washing liquid just in case traces of soap remain and contribute to the irritation. • Use sanitary pads rather than tampons.

• Always wipe yourself from the front to the back so as to reduce the chance of infection from the bowel. If you are very sensitive, white unbleached toilet tissue may be a good idea.

• Your diet should be low in sugar or sucrose, which means not adding sugar to tea and coffee, avoiding sweets, cakes, biscuits, chocolates and non-low-calorie soft drinks. For some a diet low in foods that are rich in yeast can help. Yeasty foods include alcoholic beverages (except gin and vodka), vinegar, pickled foods, yeast extract such as Marmite and many stock cubes, most packaged savoury foods including convenience meals and soups, and bread and buns and anything made from baker’s or brewer’s yeast. Occasionally it may be necessary for the diet to be even more restricted than this, but fruit restriction is rarely needed.

• Supplements may also be necessary. Consider a yeast-free multi-vitamin if you have recurrent thrush. A supplement of zinc, 20 mg per day can help, as can a supplement of iron such as ferrous sulphate, 200 mg once or twice a day, especially if heavy periods or anaemia are or have been problems.

• Capsules containing preparations of the healthy bacteria Lactobacillus acidophillus and related species are available and might help clear thrush from the gut (but not the vagina). Eating live yoghurt might also be helpful, and applying plain live yoghurt to the vagina is possibly beneficial but would be no substitute for anti-fungal medication.

• Caprylic acid is a naturally occurring fatty acid which has been reported to be an effective anti-fungal compound in the treatment of candida.

• Berberine containing plants, including goldenseal have shown natural antibiotic activity against bacteria, and fungi including candida.

• Grapefruit seed extract is another natural agent possessing antibiotic and anti-fungal properties.

• It is important to address digestive abnormalities when treating candida, and the first point of action is to improve digestive secretions. Hydrochloric acid (secreted by the parietal cells in the lining of the stomach), pancreatic enzymes (that ensure efficient digestion of proteins and carbohydrates) and bile (secreted by the gall bladder) all inhibit the overgrowth of candida and prevent its penetration into the lining of the small of intestine. Specific supplements of hydrochloric acid and digestive enzymes can be taken in conjunction with an anti-candida diet, but advice should be sought from a professional nutritionist.

• Garlic has demonstrated significant antifungal activity.

• Boosting the immune system by taking zinc, vitamin C and the herb echinacea can help with candida.

Top Sally's story

Sally was a 43-year-old headmistress who also had two young children of her own. She had been diagnosed as having thrush in her oesophagus, which was causing her great pain in the chest, particularly on waking.

‘I had continued digestive problems which had become progressively worse. My doctor had sent me for investigations. I had an endoscopy, where a telescope is passed into the stomach, and a gall bladder scan, which were clear except for the thrush that was found in my gullet. My worst problem was the extreme pain I experienced on waking each day, and the indigestion. I also had an itchy bottom, so I presumed the thrush went right through my gut. Premenstrually I felt angry and clumsy and had experienced very sore breasts. My job had become very stressful, I couldn’t get on top of it somehow. To make matters worse I had developed panic attacks which I thought would subside during the school holidays, but they didn’t. My libido had also disappeared and sexual intercourse had become painful as my muscles seemed so tight. A friend had recommended I consult a cranial osteopath for my back problem, and as luck would have it he referred me to the WNAS for help with my other problems. I was quite sceptical about diet being the solution to what seemed to be extreme symptoms. I was so desperate that I was willing to try anything, so I went along for an initial consultation, which was very probing. I came away with a programme to start on which involved following an exclusion diet, particularly wheat, foods that contain yeast, caffeine and alcohol, plus I was asked to exercise and take some nutritional supplements. At my second consultation, which was six weeks later, I was able to report that the pain on waking was only minor and had only occurred once in the last month. My itchy tail had cleared up, my period arrived unannounced with no symptoms or bloating and I felt that I was on the right track. I continued to make progress on all fronts, until Christmas. I was feeling so much better that I went for the dried fruit, chocolate, orange juice and wine. The symptoms flared up and it took a couple of weeks to calm down again, but it really brought home to me how sensitive my body was to these foods and drinks. I have taken up jogging again, which I used to love, and I feel wonderful. All my gut symptoms have disappeared, I no longer feel like I have thrush, my PMS has gone and I am coping really well with situations at work and at home. We have been juggling with my diet for the last six months, and I have gradually been able to add things back without seeing a return of symptoms. I feel very confident that I can manage my health myself now with my new
knowledge, and be there for all those who depend upon me.’