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:
- Your diagnosis is correct – there is a 30% chance of this
- 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.
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.