recent study in the New England Journal
of Medicine demonstrated
that once-weekly prophylactic oral
administration of 150 mg of fluconazole (Diflucan®) can greatly
reduce the recurrence rate of vulvovaginal candidiasis among women
who suffer from repeated recurrences.1 While this study provides another
useful treatment option for women who experience frequent yeast infections,
the conventional approach to treating this condition remains inadequate
because it continues to ignore certain simple, safe, inexpensive, and
effective methods of controlling candidiasis.
As many as 1 in 12 women suffers from recurrent vulvovaginal candidiasis.
While recurrent yeast infections are associated with diseases such as
diabetes and AIDS, most women who suffer from this problem do not have
these diseases. Topical or oral antifungal agents are usually effective
for treating acute episodes of candidiasis; however, the condition frequently
recurs, resulting in frustration for both patient and doctor.
In the new study, 387 women who had recently been treated for a recurrent
episode of candidiasis were randomly assigned to receive fluconazole
or placebo for six months, after which they were observed for another
six months without treatment. During the treatment period, only 9.2%
of the women receiving fluconazole developed a yeast infection, compared
with 64.1% of those in the placebo group (p < 0.001). After treatment
was discontinued, however, relapses were common; just 42.9% of the women
in the original fluconazole group remained disease-free for the entire
12 months. The authors of the report concluded that recurrent candidiasis
can be safely controlled by prophylactic administration of fluconazole;
they acknowledged, however, that it is difficult to cure the disease.
The lack of success in managing recurrent yeast infections was echoed
in an accompanying editorial.
Some cases of recurrent vaginal candidiasis are, indeed, difficult to
manage successfully. However, I have found, as have many other practitioners
interested in natural medicine, that a large proportion of Candida sufferers
will achieve far better results if they follow a program that includes
dietary modification, lifestyle changes, and use of certain supplements.
It is not uncommon for women to report that, since starting such a program,
their yeast infections have been controlled for the first time in many
years. This type of program is not new—the information has been
widely disseminated for more than 20 years by the late Dr. William Crook2 and
others—but for some reason, the average doctor has little perceptible
interest in trying such an approach on difficult patients.
One of the most important factors for preventing Candida recurrences
is to restrict one's intake of added sugars and other concentrated
sugars (as in fruit juice). In a study of 46 women with recurrent vulvovaginal
candidiasis, dietary histories revealed that 40% were consuming excessive
amounts of sucrose. Of those who were consuming excessive amounts of
sucrose, 90% remained free of yeast infections for more than one year
while restricting sucrose intake.3 In my experience, many women find
that their yeast infections stop when they stay away from the sweets,
but recur soon after they start eating sugar again. The mechanism by
which sugar consumption promotes yeast flare-ups is not fully understood,
although it may have something to do with suppressing the immune system
and feeding the yeast. Despite the lack of a proven mechanism of action,
many women would prefer changing their diet to taking Diflucan once a
week for the rest of their life.
Some women also seem to benefit from identifying and avoiding allergenic
foods. Repeatedly eating allergens stresses the immune system, potentially
decreasing its capacity to fight opportunistic infections such as Candida
albicans. An allergic reaction might also cause inflammation of the vaginal
mucosa, rendering it more susceptible to infection. Drinking alcohol
also seems to cause problems for many with recurrent yeast infections.
Dr. Crook and others have advocated the avoidance of foods that contain
yeast and mold. In my experience, more than half of women with recurrent
yeast infections are able to eat those foods without causing problems,
but some women clearly fare better when they avoid dietary yeasts and
Supplementing with probiotics, either in concentrated form or in yogurt,
may also provide benefit. In one study, 13 women with recurrent Candida
vaginitis consumed eight ounces of yogurt per day for six months, and
then no yogurt (control period) for an additional six months. The yogurt
used in the study contained greater than 108 colony-forming units of
Lactobacillus acidophilus per milliliter.4 The mean number
of vaginal candida infections per person was 0.38 during the yogurt period
during the control period (85% reduction with yogurt; p < 0.001).
The prevalence of asymptomatic Candida colonization of the vagina or
rectum was 74% lower during the yogurt period than during the control
period (p = 0.001). In another study, 50 women received weekly vaginal
application of two specific strains of lactobacillus (L. rhamnosus GR-1
and L. fermentum RC-14; these strains are not yet commercially available)
for up to one year.5 No episodes of Candida vaginitis occurred, whereas
approximately 200 such infections would have been expected during that
period of time.
Garlic is also used empirically by some practitioners, because of its
documented antifungal activity in vitro, although there have been no
clinical trials in women with recurrent candidiasis. Caprylic acid, pau
d'arco tea, and other natural substances with antifungal activity
also appear to be of benefit in some cases. Lifestyle changes, including
avoiding unnecessary use of antibiotics, birth control pills, and glucocorticoids,
are often recommended by "alternative" practitioners, and
appear to be helpful for some women.
It is not clear why conventional medicine refuses to advance beyond the
take-this-drug-and-don't-wear-pantyhose approach to recurrent candidiasis.
Admittedly, the natural treatments discussed in this editorial have not
been subjected to randomized clinical trials. However, doctors make recommendations
all the time that do not meet the rigorous criteria of evidence-based
medicine. The resistance among conventional doctors probably has something
to do with a bias against natural medicine, particularly against treatments
that require a great deal of time for education and handholding. Whatever
the explanation, it is not a good one, because millions of women suffering
from recurrent yeast infections are receiving substandard care. The authors
of the fluconazole study inadvertently admitted that fact, in somewhat
of a Freudian slip, in the Discussion section of their article. They
apparently meant to say that the outcome is often disappointing, despite
the best that modern medicine has to offer. What they actually did say
was that recurrent Candida vaginitis is a "poorly managed condition."
Alan R. Gaby, MD
1. Sobel JD, et al. Maintenance fluconazole
therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004;351:876–883.
2. Crook WG. The Yeast Connection and the Woman.
Professional Books, Jackson, TN, 1995.
3. Horowitz BJ, et al. Sugar chromatography studies in recurrent candida
vulvovaginitis. J Reprod Med 1984;29:441–443.
4. Hilton E, et al. Ingestion of yogurt containing Lactobacillus acidophilus
as prophylaxis for candidal vaginits. Ann Intern Med 1992;116:353–357.
5. Cadieux P, et al. Lactobacillus strains and vaginal ecology. JAMA 2002;287:1940–1941.