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From the Townsend Letter for Doctors & Patients
November 2004

Recurrent Candidiasis: One Step Forward, Still Backward
by Alan R. Gaby, MD
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A 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 molds.

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 and 2.54 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.


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