How to solve the misery of recurrent yeast infections, by DR KAYE

I’m a woman in my mid-50s and I’m itchy and sore down there. I’ve tried an over-the-counter thrush treatment but that hasn’t worked, what should I do?

Dr Philippa Kaye answers: For mid-life women, persistent itching and soreness that does not improve with over-the-counter thrush treatment is unlikely to be thrush. Instead, it is more likely to be a symptom of the menopause.

During the menopause – which typically occurs when women are in their late 40s or early 50s – the body produces far less of the sex hormone oestrogen.

The triggers many of the classic menopause symptoms, including hot flushes, night sweats and disrupted sleep.

However, falling oestrogen levels also can trigger uncomfortable changes to the vagina and vulva.

The hormone is crucial for a healthy intimate area.

And, without it, the skin of the vagina and vulva can become thinner, drier and more fragile. This leads to irritation, burning, itching and often discomfort during sex. This is known as genitourinary syndrome of the menopause, or GSM.

This is one of the most common complaints I hear in my clinic. In fact, most days I see women suffering from these uncomfortable – and frankly, a bit embarrassing – symptoms.

Moreover, in many cases, these symptoms are mistaken for vaginal thrush. It’s easy to see why.

Vaginal thrust is a common yeast infection, caused by an overgrowth of a fungus called Candida. Patients usually report intense itching and soreness, as well as redness or swelling of the surrounding skin.

There is also typically a thick, white vaginal discharge.

Candida lives on the skin, so it’s not something that is ‘caught’ like an infection. Instead, it can occur due to an imbalance of bacteria and yeast. Pregnant women, diabetes patients or those with irritated vaginal skin, such as due to tight clothing or overuse of scented soaps, are more at risk of vaginal thrush.

However, crucially, menopausal women are less likely to develop thrush. This is because lower oestrogen levels make it harder for yeast to grow.

The problem is that, as I’ve noticed in my clinic, many menopausal women do not know this. Instead, when they experience uncomfortable vagina and vulva symptoms, they assume the problem is thrush.

So, they then go out and try an over-the-counter thrush treatment, like Canesten, or clotrimazole, a common antifungal drug that can be taken as a cream or pessary. There is also a popular antifungal tablet called fluconazole.

The drug is highly effective at combatting thrush, but it’s not going to do anything to help with menopause symptoms.

Instead, here are a few simple steps that women struggling with this issue can take to ease their symptoms.

The most effective treatment for GSM, however, is vaginal oestrogen, which a GP can prescribe or, in some cases, can be bought over the counter without a prescription.

This medicine replaces the hormone directly in the affected tissues and reverses many of the changes causing symptoms. Unlike standard hormone replacement therapy, it works locally, meaning it is applied directly to the vulva and vagina.

It also means that only tiny amounts of the replacement hormone are absorbed into the bloodstream, so it is suitable for most patients, including many who cannot take full HRT – such as women with a history of breast, ovarian or womb cancer.

Vaginal oestrogen comes as a cream, pessary or tablets – which are inserted directly into the vagina.

Typically, it is used daily for two weeks to build up the effect, then reduced to twice weekly for maintenance.

Recently, some vaginal oestrogen products, like Gina tablets and Ovesse cream, have become available without prescription from most pharmacies. These usually cost around £20 to £30 a month.

However, a GP should be able to prescribe vaginal oestrogen to most patients who require it, for a fraction of the over-the-counter cost.

Another alternative is a vaginal ring, which releases a steady dose of oestrogen and is replaced every three months.

But, as I explain to my patients, there are other steps patients need to take to tackle these symptoms, beyond taking vaginal oestrogen.

This includes cutting out anything that could be aggravating the already sensitive skin.

The vagina is self-cleaning, so internal washing or douching is unnecessary and often harmful.

The external genital area, known as the vulva, should be washed with plain water or a simple moisturiser rather than soaps or so-called feminine hygiene products, even those labelled ‘gentle’ or ‘pH balanced’.

Bubble baths, bath bombs and fragranced products are common triggers for irritation and are best avoided altogether.

Regular use of a vaginal moisturiser can make a noticeable difference. These are designed to hydrate the tissues and are used several times a week rather than just during sex.

Products such as YES VM vaginal moisturiser typically cost between £10 and £15 and can be bought over the counter. They should help restore comfort – though they do not treat the underlying hormonal cause.

Lubricants are also important, particularly if symptoms have a negative impact on sex.

Water-based lubricants are usually the best tolerated and are safe to use with condoms. Options such as Astroglide or YES WB cost around £5 to £10.

Products containing glycerin, fragrances or ‘warming’ ingredients can worsen irritation and are best avoided.

Oil-based lubricants last longer but are not compatible with condoms, while silicone-based options are very slippery but can stain fabrics.

It’s also important to remember that, while GSM is very common, it is not the only cause of persistent vulval itching.

Skin conditions such as lichen sclerosus or eczema can present in a similar way and require different treatment, often with prescription creams. Infections other than thrush, including bacterial vaginosis or sexually transmitted infections, can also cause irritation, although these are often accompanied by discharge or odour.

In rare cases, itching can be due to vulval or vaginal cancer.

For this reason, anyone with persistent intimate itching should see their GP for an assessment.

The right diagnosis and targeted treatment can make a significant difference to comfort and quality of life.

• Write to Dr Philippa Kaye at Health, Daily Mail, 9 Derry Street, London, W8 5HY or email: health@mailonsunday.co.uk – include contact details. Dr Kaye cannot enter into personal correspondence. Replies should be taken in a general context. Consult your own GP with any health worries.