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vaginal discharge, yeast

When your OTC vaginal yeast medication fails don’t just call for a Diflucan

Candida albicans, office microscopy

Candida albicans, office microscopy

So you think you have a yeast infection and you buy an over-the-counter (OTC) treatment, but four days later you are still very itchy/irritated/burning like crazy. The next step, for most women, is to call their GYNO and ask for fluconazole, known by many under the brand name Diflucan, or to retreat with a OTC topical. Both options are wrong. Here’s why.

First of all you need this background information:

  • OTC yeast medications are as effective as fluconazole (Diflucan) and both will cure 85-90% of yeast infections. They are similar types of medications (a class called azoles), meaning they work in the same way. If your yeast is resistant to one azole it is likely resistant to all of them.
  • Diagnosing yeast infections at home is notoriously difficult. Many studies tell us women are only correct about 1/3 of the time (FYI many doctors are not that good either as the skill of identifying yeast under the microscope is rapidly deteriorating. There was even an op-ed in an OB/GYN journal recently lamenting that fact).
  • The definitive diagnosis for yeast, meaning the gold stand, is a culture from the vagina called a mycology culture.

If you have an itch/burning/irritation and you treat it at home as a yeast infection with a OTC there are two possible options:

  1. Your diagnosis is correct – there is a 30% chance of this
  2. Your diagnosis is incorrect – there is a 70% chance of this

If you were right then there is a 85-90% chance that you should be better. If you guessed correctly and aren’t better more of the same (i.e. trying fluconazole/Diflucan or another OTC medication) is not likely to be any better because the oral and topicals work in the same way.

If you are not feeling better after treatment (which will happen 75% of the time just looking at the statistics) there are five possible scenarios:

  • You had a less typical yeast strain. Neither OTC or fluconazole/Diflucan will work in this scenario. This strain of yeast can only be diagnosed with a mycology culture. You need to see your doctor/nurse practitioner (NP)  for this.
  • You have regular yeast (Candida albicans) but it isn’t susceptible to the OTC product. In this case fluconazole/Diflucan won’t work either. You need to see your doctor/NP for this diagnosis as well and you also need a mycology culture.
  • The yeast is invasive, meaning there is a lot of in the skin of the vulva and the mucosa of vagina. This requires an extended treatment. You need to see your doctor for this diagnosis as one or two pills of Diflucan will probably not cut it. This scenario is more common if you have diabetes or have immune system issues.
  • You had yeast but for some reason not related to any of the above the treatment failed and so you really just need a second treatment. Because this is not that common a mycology culture is recommended to rule out the other scenarios.
  • You never had yeast to begin with. This is by far the most common scenario.

Put another way, if 100 women use OTC medication for vaginal yeast, 70 will have persistent symptoms because they never had yeast to begin with and 5 will still have persistent symptoms related to yeast. That means if you have persistent symptoms there is a 93% chance you never had yeast and a 7% chance that you did, but need further information to treat. The chance that more of the same will help is very slim.

yeast

Other clinical pearls:

A bad yeast infection can take seven days to feel a lot better, An antihistamine, like Zyrtec or Claritin, will help you feel better faster and a low dose topical steroid on the vulva (labia and vaginal opening) will also help if there is a lot of external irritation

But the OTC always fails for me and the Diflucan always works! I hear this a lot. This is unlikely related to the type of medication (OTC vs prescription) and more a mechanical issue – some women place  the vaginal medication too low in their vagina (if the tissues are really inflamed it can be harder to get high enough). The other possibility is the irritation wasn’t due to yeast, but given the extra time it took after using the topical to call the doctor and get the fluconazole things cleared up on their own.

The topicals often feel like they work faster because they are soothing, especially clotrimazole. This doesn’t mean they kill yeast better, rather the base is soothing and just having something on the inflamed tissue helps with symptoms. This can lead many women to erroneously think they have chronic yeast infections because when they use the topicals they feels better for a while. One scenario is they have recurrent yeast, but the other far more common scenario is they have chronic irritation from a non-yeast cause and the topicals just provide a temporary relief that has nothing to do with any yeast-killing action.

If you use OTC topicals understand there is only a 25% chance you will feel better, however for many women it is a lot cheaper than a co payment so I understand why people want to use them. If they have always worked for you within 3-4 days that’s great. HOwever, if you have a history of using them with limited success  but getting in for a full evaluation isn’t possible/practical then consider this sequence:

  • Start a 3 -day clotrimazole OTC (although if miconazole works great for you there is no need to switch).
  • If you are very irritated also start an antihistamine, like Zyrtce, and take once a day. Use some topical 1% hydrocortisone on your vulva if that is irritated.
  • Call and set up an appointment the day you start the yeast medication for 6-7 days out. There is a 75% chance you will need this and you are more likely to get the appointment time you want calling 7 days ahead than the day of. Why set this up for day 6-7? The intravaginal product will stay around for 3 days affecting the exam, so if you used the 3 day treatment you can’t really be evaluated until day 6 or 7.
  • If you feel better before day 7 cancel your appointment. Try and give 24 hours notice.
  • If you still have symptoms and keep your day 7 appointment insist on a vaginal mycology culture.

Like all things on the Internet, this post isn’t direct medical advice.

Discussion

18 thoughts on “When your OTC vaginal yeast medication fails don’t just call for a Diflucan

  1. Please don’t forget the fact that if you have recurrent yeast infections you may need to have your blood sugar checked since it is very possible that you have diabetes!

    Posted by Crogram | August 11, 2015, 1:55 pm
  2. So if, as stated in the pie chart, 93% of the women who have vulvovaginitis and failed OTC azole treatment never had yeast to begin with, what are some of the causes? BV?

    Posted by Kim | August 11, 2015, 3:00 pm
  3. What if you are currently taking antibiotics?

    Posted by Nicole | August 12, 2015, 2:24 pm
  4. Thank you for your always informative posts on candida. As someone who has struggled for 3 years with recurrent infections with no diabetes (confirmed by culture), it was very frustrating to be prescribed Diflucan because of the harshness on the liver and the side effects. Now I know the reasoning behind why it never seemed to work. Additionally, I have almost non-existent progesterone levels and low thyroid. It’s almost like clockwork- day 14 = the return of the discomfort. It probably about shocked the doc when I told him I was already making my own boric acid pessaries when he wanted to call it into the pharmacy. This was because I found you on a desperate Google search- looking for truth when there are so many people trying to make a buck off “natural” diets, supplements, and blog traffic with “expertise” on candida. You have made a real difference in my life.

    Posted by b | August 18, 2015, 11:47 pm
    • I don’t take Biotin; However, I been taking Fluconazole on and off for a few months..I seems to help, but the next month will return. I do have Thyroid and have pills that level my Thyroid, do you think my pills are causing this? I been to my OB many many times and that does not help me at all. I don’t know what else to do.

      Posted by Carmen | April 18, 2016, 10:51 am
    • I have recurrent bv followed by yeast. U treat one with antibiotics then the other one comes on with a vengeance a few days later. Miserable cycle. I am curious about the boric acid. How many days do you use them ? I am seeing evidence of 21 days, but I go to a specialist ob /infectious disease Doctor and I don’t wanna be taking something that close to my appointment bc I want him to see what’s going on. Suffering from a nasty yeast infection now and sick of taking antifungals.

      Posted by Missy | June 8, 2016, 2:34 pm
  5. I keep reading articles stating that we shouldn’t wash the inside of our lady parts but there is kind of chunky discharge present (yeast infection)… Shouldn’t I wash it out?

    Posted by S | September 14, 2015, 4:50 pm
  6. Thank for this guide Dr.Jen…..My question is, “is it possible that the yeast infected spots also show bleeding”? I’ve noticed it under my armpits a few times. I think it is because of itching

    Posted by Stephine Auxier | October 2, 2015, 7:09 am
  7. I just want to let you all know I diagnosed myself after visiting my OB Doctor multiple times. I took Diflucan (didn’t suit me) and I got the infections multiple multiple times for about 6 months!! Well the culprit was—— BIOTIN!!! Yes Biotin! I was taking the 5000mg Biotin for my hair skin n nails and imagine getting cured and then getting the infection the following week! I noticed when I went on a family holiday to Vegas that I didn’t get the infection, I noticed I wasn’t taking my biotin vitamins during the trip and was fine, as soon as I returned and took one– guess what? The irritation began within hours. Well I knew then, stopped taking the Biotin and my infections ceased to exist. I would highly urge all if you who seem to be doing fine but keep getting infections to keep a journal, it might reveal something to you that you might not have noticed. It might help. Take care.

    Posted by Gia | March 28, 2016, 9:04 pm
    • I have been researching for 3 days as to why I have had a yeast infection each month for the last two months when I normally don’t even have one every year. As I was reading your post I had an Ah-Ha moment. I begin taking a hair, skin, and nail vitamin in January that has a high dosage of biotin.
      Thanks for the info!

      Posted by Shawnte | March 31, 2016, 6:30 pm
  8. Hmmm. I just paid a $75 after-hours copay to be given two diflucan pills after explaining my symptoms. No swab for the lab, no urine test and a “Come on back if it doesn’t feel better.” Yeah, thanks, Doc.

    Posted by LAB | May 21, 2016, 9:14 am
  9. The over the counter medications make me itch and burn more. This does not happen with Diflucan.

    Posted by Migdalia | July 8, 2016, 8:02 am
  10. So…. my doc confirmed it was yeast. Been through 3 rounds of cream (one prescription), two weeks of diflucan, and then two more days of diflucan. Still the same. What the heck is going on? I don’t have diabetes. I have a compromised immune system, but I can’t see why the medications don’t work at all. You’d think it’d help a little bit. I’m at a loss. I’ve had this thing for 7 months now and they just keep throwing diflucan at me. Is there anything that isn’t a “zole” that could be used? I’ve been searching the web, but I find nothing.

    Posted by marnasa | August 12, 2016, 4:23 am
    • omg @ Marinasa, our stories are similar. I have had a yeast infection every month since February of this year (6 months now) right after my period. Ive been prescribed diflucan pills and cream. I am 29 years old and have only had two previous yeast infection prior to this 2016 year. When given the prescription all my symptoms disappear and I feel “normal” again but about two days after my period ending I get symptoms of another positive yeast infection. I have been tested for every STDs and all is negative. My doctor decided to prescribe my husband cream as well as a “test” ( she was thinking maybe he had yeast too). We both used the cream for 7days and used a condom after the 7 days was up anytime we decided to have intercourse. But our “test” failed. I got the yeast infection once again:/. Going back to my GYNO this Thursday 8-18-2016. So frustrating and very uncomfortable:/. Anyone with similar symptoms or solutions? What helps you? over this!!!

      Posted by overthis | August 16, 2016, 5:38 pm
      • Hi am 24y.o and get exact same thing as you. My dr. Said it was maybe because i was allergic my own secretions. Same thing for my periods, irritation on my big lips, mainly right one. I keep washing with hot water and have taken itraconazole tabs bt these dont really work!!😡😡😡😡
        Please contact me, my problem needs experience nt just a dr.!

        Posted by Fungus war | September 7, 2016, 1:32 am
  11. I have been having ongoing yeast infection symptoms for over a year. It was a lot worse when it first started, I tried over the counter treatments, diflucan, and other prescription creams but nothing helps. It always comes back around my period or when I have sex, which is rare because it hurts too bad when i try. One thing that has helped my symptoms has been a natural probiotic called “yeast away” you can get it on amazon or from a natural health store. While my symptoms aren’t as bad and sometimes go away completely they still come back. I would highly advise taking probiotics though, it has helped more than any prescription has. Good luck everyone.

    Posted by Namelyss | September 16, 2016, 12:14 pm
  12. Dr. Gunter,

    I’m a huge fan of your blog! I really appreciate what you do here.

    I know you can’t give me medical advice, but I’ve been struggling with a very long-term case of vulvovaginal candidiasis (RVVC), and I wanted to see if you’d offer your opinion on this whole business of fluconazole being actually quite ineffective against RVVC. My doctors, the experts whose expertise I’d like to rely on, don’t seem to want to do any research for me. As a disclaimer: I am a full-on believer of evidence-based medicine, and of reason and empiricism in general. I’m not trying to voodoo my vagina, and I know that my vagina is not isolated from the rest of my body, which has some other complex stuff going on. All that being said. . .

    From the few papers I’ve read, fluconazole is good at suppressing the symptoms of RVVC, but it’s crap at actually defeating it. It seems like the drug itself is not good at penetrating long-standing candida biofilms, so it can’t really break into the main source of ongoing infection. Are you familiar with these stupid biofilms? If the drug is clearly not tackling the cause, why is the only apparent protocol for dealing with RVVC to put women on a six-month once-a-week course of fluconazole? The outcomes for this course of treatment aren’t even particularly good!* My symptoms are totally suppressed (like, gloriously, fully normal vagina!) while I’m on Diflucan, and about six days after taking it: Bam! It comes right back. It’s disruptive and depressing.

    My question is: Is there a better way? Is there a better drug? What do you recommend for your patients who are dealing with RVVC when fluconazole ultimately fails or only manages to keep infection at bay?

    I really can’t find anything. All the literature just speaks to how unsatisfactory the current protocol is. There’s all sorts of microbiology research about how various essential oils (clove, lemongrass) seem to bust the candida biofilm’s ass in vitro, but nobody’s turned these compounds into drugs yet? I found a paper testing a fluconazole microemulsion that incorporates some of these other biofilm-busting antifungals. Should I look for a clinical trial?

    Even if you don’t get around to responding to this, I just want to thank you for being such a forceful feminist presence on the Internet. And for reading this long, inappropriately soliciting comment.

    Emma

    *”In spite of the high rate of relapse of symptomatic vaginitis shortly after the cessation of suppressive therapy with fluconazole in our study, the number of patients who remained free of infection at one year was significantly higher in the fluconazole group [42.9 percent] than in the placebo group [21.9 percent]. The decision about how to treat patients whose infection recurs after the discontinuation of fluconazole therapy remains controversial. Clinical experience has indicated that a majority of patients elect to repeat the six-month maintenance regimen with fluconazole; however, the optimal duration of secondary suppressive prophylaxis remains unknown, even though patients receiving the repeated regimen have had a level of protection that is similar to that in our study group. There have been anecdotal reports of women who became asymptomatic but dependent on fluconazole therapy and were monitored for several years, with no adverse effects.”
    Sobel, Jack D., et al. “Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis.” New England Journal of Medicine 351.9 (2004): 876-883.

    > This doesn’t sound particularly promising to me!

    Posted by Emma | October 27, 2016, 4:08 pm

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