Vulvovaginal Candidiasis (VVC)
The most common type of Candida (yeast) to cause infections is Candida albicans, which is the source of 80-90 percent of vaginal infections in women. Vulvovaginal Candidiasis is the second most common cause of vaginitis and can be more than annoying for women who frequently experience this type of infection.
While it is normal for Candida to colonize (or live) in the vagina, it can sometimes overgrow causing inflammation of the vulva and vagina. This leads to the typically experienced symptoms of genital burning, itching, redness, pain, and a thick, white cottage-cheese-like discharge.
Why Do Some Women Experience Frequent Yeast Infections?
There are many factors and/or triggers that can predispose women to having a vaginal yeast infection, such as:
- Use of antibiotics
- Use of estrogen-containing contraceptives
- Pregnancy (because of the high estrogen level)
- Uncontrolled diabetes mellitus (because of the high sugar)
- Sexual activity (the vagina is healthier when it is more acidic, but semen is alkaline and can affect the acidic level in the vagina)
- Human Immunodeficiency Syndrome (HIV) or any condition that affects the immune system
- Tight-fitting clothing
- Improper vulvovaginal hygiene
The majority of women experience at least one vaginal yeast infection throughout their lifetime, and close to half of these women will experience two infections or more. VVC is considered recurrent when a woman has at least 4 separate infections within a 12-month time span. Persistent, or treatment resistant, VVC occurs when a woman continues to experience symptoms for prolonged periods despite receiving treatment.
It is estimated that 70-75% of women will experience at least one episode of VVC in their lifetime. An international survey of 6,000 women demonstrated that by age 25 about 10% of women who have ever had a vaginal yeast infection, will experience recurrent VVC.1 This percentage rises to 25% in these women by age 50.1
Both recurrent and persistent VVC can significantly impact a woman’s life. The symptoms of these infections can negatively affect sexual activity, mental health, and even work productivity. Subsequently, it is no surprise that recurrent or prolonged experience of VVC infections have been shown to adversely impact a woman’s quality of life and overall health status.
Prevention and Treatment of VVC
In order to help prevent vaginal yeast infections, women should:
- Maintain good vaginal hygiene
- Wear loose cotton underwear
- Minimize antibiotic use, as able
Uncomplicated VVC infections
Uncomplicated VVC infections are typically treated with over-the-counter preparations of vaginal fluconazole, an antifungal treatment. If evaluated by a physician, VVC can be treated by prescription oral or vaginal azole antifungals, such as fluconazole, clotrimazole, ketoconazole, itraconazole, and terconazole.
Complicated VVC infections
Complicated infections, such as recurrent VVC, are more difficult to treat. These infections may require a longer duration of treatment and the use of a stronger azole antifungal, such as terconazole and/or supplemental vaginal boric acid therapy.
Rare VVC infections
In rare cases, certain patients may need be treated with stronger antifungals such as compounded amphotericin B or flucytosine. Many women may also need to use longer term prophylactic therapy with azoles and/or boric acid to prevent the recurrence of VVC. It is important to note, that while many primary care physicians and OB/GYNs are quite capable of treating uncomplicated VVC infections, complicated infections may require specialist care with a physician more experienced in gynecologic infectious disease.
New Medication Approved to Treat VVC
After several years of no new treatments for vaginal yeast infections, the FDA just recently approved the use of Brexafemme® (Ibrexafungerp), a one-day oral antifungal treatment for complicated, recurrent and azole-resistant VVC. This medication was approved based on the results of a two Phase 3 studies showing Brexafemme® works well as a VVC treatment and is well-tolerated by women and is a welcome new addition.
What do you need to know about Brexafemme®
However, this medication would be an alternative treatment for a subgroup of non-pregnant and non-lactating women suffering from recurrent and azole resistant VVC. Ongoing VVC symptoms, as discussed earlier, can be irritating for women. There are risks to consider with the current available treatments, especially when strong antifungals and/or prolonged use of azoles are required. This new medication would offer effective one-day treatment for their VVC. The recommended dose is 300 mg (two 150 mg tablets) twice a daily, 12 hours apart, with or without food, for one day.2
FDA approval application included research data from two randomized control trials using Brexafemme® versus placebo (no treatment). The first trial showed about 50% of participants had improved symptoms after two weeks of treatment and 60% four weeks after treatment.2 The second trial showed about 64% of participants' symptoms improved two weeks following treatment and 73% four weeks after treatment.2
The most common side effects of Brexafemme® were gastrointestinal symptoms, such as diarrhea, nausea, vomiting, abdominal pain, and also dizziness.2
Is Brexafemme® cost effective?
The cost of Brexafemme® may be the most significant barrier to it being prescribed to patients. The current cost prediction of it is much higher than the cost of fluconazole, which is listed for four tablets at the lowest cost.
However if the price remains at the predicted amount, the cost of Brexafemme® would be justifiable in a subset of women with complicated, recurrent or azole resistant VVC. Also, it may offer an alternative therapy for those unable to use fluconazole or in whom it doesn't work. Currently, women with recurrent VVC are on multiple doses of azoles and utilize numerous doctors’ visits or phone calls.
Some patients with non-albicans candida or azole resistant VVC may spend out of pocket money on compounded amphotericin B and flucytosine, which are effective in >70% in this subset of patients. Some women do not have access to compounded pharmacy or specialists and may benefit from Brexafemme®. The cost of new and old medicines are a continued issue, but it is nice to have a new option for women with VVA.
Be Strong, Be Healthy, Be in Charge!
-Tara Iyer, MD, Tiffany Cochran MD and Dr. Tosin Goje
- Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Prevalence of recurrent vulvovaginal candidiasis in 5 European countries and the United States: results from an internet panel survey. Journal of lower genital tract disease. 2013 Jul 1;17(3):340-5.
- FDA resources page. Food and Drug Administration Web site. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214900s000lbl.pdf. Accessed June 4, 2021.
- Kaplan. S. F.D.A. approves pricey pill to treat vaginal yeast infection. New York Times. https://www.nytimes.com/2021/06/02/health/fda-vaginal-yeast-infection.html. Accessed June 4, 2021.
- SCYNEXIS announces submission of new drug application to the U.S. food and drug administration for oral ibrexafungerp for the treatment of vaginal yeast infection. SCYNEXIS Web site. https://ir.scynexis.com/press-releases/detail/221/scynexis-announces-submission-of-new-drug-application-to. Accessed June 4, 2021.
Dr. Tara Iyer is a Senior Women's Health Fellow in Cleveland Clinic's Specialized Women's Health Fellowship program. She is a graduate of the Saint Joseph Hospital Family Medicine Residency Program at SCL Health and has numerous student awards and publications.
Dr. Tiffany Cochran is a Senior Women's Health Fellow in Cleveland Clinic's Specialized Women's Health Fellowship program. Dr. Cochran received her Bachelor of Science from Valdosta State University and her Doctorate of Medicine from Morehouse School of Medicine. She also has an MA in Healthcare Administration.
Oluwatosin Goje, MD who leads the Reproductive Infectious Diseases Program at Cleveland Clinic, is an Obstetrician Gynecologist fellowship-trained in Infectious Diseases from the Medical University of South Carolina, Charleston, SC.
- How to Properly Care for Your Vulva
- How to Keep the Cost of Medications Down
- Why Women Should Focus On Their Own Health
- What is a Woman to do about BV? New one-day Treatment for Bacterial Vaginosis
- Dyspareunia, or Pain with Sexual Activities: Many Options for Relief
- Preventing Vaginal Infections
- Vulvovaginal Disease