Vulvovaginal candidiasis (VVC) which is more commonly known as yeast, thrush or fungal vaginal infections, and bacterial vaginosis (BV) are considered recurrent if there are at least four episodes occurring within one year.

There are many people who experience recurrent vaginal infections across the globe and these infections can have severe impacts, causing everything from feelings of shame, physical discomfort, pain and negatively impacting their sex lives.

Studies have shown that recurrency rates of BV are at 15-30% within the first 3 months1 and at more than 50% within a year after a person takes the oral antibiotic metronidazole treatment2. BV relapses occurred for around 44% of the patients followed up 24 months even after more aggressive initial antibiotic treatment3.

Yeast infections (VVC/ thrush) will affect 75% of women at some point in their life. Half of the women that get pharmaceutical treatment for VVC (yeast infections) will experience the infection again, and 9% globally will experience the condition recurrently4. That’s nearly one in 10 women.

If this is you, and you are overwhelmingly frustrated by the impacts on your life and relationships, know you are not alone.

In this article we cover 

  • Why do vaginal infections, yeast (VVC, thrush) or bacterial vaginosis, keep coming back? 
  • What are the treatment options for recurrent vaginal infections?
  • How can you avoid recurrent vaginal infections in future?

1. Why do vaginal infections keep coming back?

You’re doing all the right things, you’ve been to the GP, taken your antibiotic or anti-fungal treatment, yet the infection keeps recurring. Why?

There are several possible reasons why vaginal infections keep coming back. 

1. Recurrent vaginal infections can be due to inadequate treatment. This could include: 
  • Resistance of bacterial or fungal organisms to therapy. Unfortunately, bad bugs get smarter to survive. Repeated use of antibiotic or antifungal therapy may no longer kill the pathogens. The type of pathogen can also be less susceptible to prescription treatment. For example, certain Atopobium vaginae bacterial strains have shown a high-level of resistance to metronidazole treatment5.
  • Creation of a biofilm on the vaginal wall. Bad bacteria have the ability to create a biofilm layer which adheres to the cells of the vaginal wall, preventing the treatment from reaching the pathogens. So, the biofilm acts as a reservoir of bacteria and protects them from the effect of an antibiotic. One study took 18 BV patients treated with oral metronidazole for 1 week, and followed them up to 5 weeks after treatment. Even though all patients initially recovered, after the treatment dense and active bacterial biofilms were invariably re-emerging. These biofilms consisted predominantly of the main BV bacteria: Gardnerella vaginalis and Atopobium vaginae6.
  • Incorrect use of treatment. Patients missing treatment doses of antibotics for vaginal or urinary infections may lead to bacterial resistance to the treatment.

    2. Certain lifestyle choices represent higher risks for recurrent vaginal infections. Although we advise you of the research in this space, we believe in empowering women to live the life they want in a shame-free way. You do what feels good and right for you.

    • Sex. Sadly, BV relapses are significantly correlated with new sexual contacts. A 6-year follow up study was conducted on 44 women treated for bacterial vaginosis. Half of those patients were free of BV while the other half had relapses. The group that had relapses had more new sexual partners than the group that didn’t have relapses7.
      In a separate study following up 121 patients treated for BV for 12 months it was found that those with a regular sex partner (male and female) had a higher recurrence rate of BV and abnormal vaginal flora. This study suggested that women without a regular partner were more likely to use condoms (more than 50% of the time) which may protect them being reinfected by a regular partner. The highest cure was among women who abstained from having sex or consistently used condoms during treatment8.
    • The Pill. Even though a lot of research studies showed that hormonal influence is not significant in BV recurrency, there still is some evidence that estrogen-containing contraceptives may modify the effectiveness of BV treatment9.

      2. How can recurrent vaginal infections be treated?  

      Antibiotics for recurrent BV treatment

      Prescription treatment for recurrent BV consists of an extended course of antibiotics including metronidazole treatment (500 mg twice daily for 10-14 days). If ineffective, metronidazole vaginal gel 0.75% is applied for 10 days, followed by two times per week for 3-6 months. Clindamycin and tinidazole are used in the treatment of recurrent BV mostly on patients that have an infection resistant to metronidazole treatment.

      Secnidazole is another treatment option, convenient due to one-time dosing10. It also has a broad spectrum of activity against anaerobic microorganisms and stays longer in the circulation than metronidazole.

      Antifungal treatment for recurrent fungal infections

      Prescription treatment for recurrent fungal infections is either clotrimazole 500 mg vaginally, or fluconazole 150 mg orally.

      Vaginally applied nystatin seems to be helpful especially for the treatment of fluconazole resistant and non-Candida albicans species. Maintenance dose found in the literature is fluconazole 200 mg once a month for a year. The issue with long-term use of fluconazole is its safety risks, which include liver toxicity, drug interactions, and pregnancy warnings11.

      3. How can recurrent vaginal infection episodes be reduced? 

      The good news is that there are clinically proven ways to reduce the recurrence of vaginal infections. 

      Most clinical studies support probiotics in the maintenance of vaginal health, and no adverse effects have been reported. In a nutshell, probiotics increase the healthy bacteria in the vaginal microbiome, producing healthy lactic acid and helping to fight the pathogens that cause infection.

      Check out what you should look for in your vaginal probiotic in our article on how to find the best vaginal probiotic for you.

      However, we have summarised the data for you below. It gets a bit technical but if you can persist it’s worth it:

      • BV - According to a review12 of published randomised controlled trials over a period of more than 20 years, the use of Lactobacillus rhamnosus, GR-1® and Lactobacillus reuteri, RC-14® at a dose of at least 108 CFU/day for 2 months has been shown to ”normalize the vaginal flora, help cure the existing infection and prevent recurrence of BV“. The use of probiotics is encouraged for long term control of BV relapses especially after treatment with metronidazole.
      • It was also found that women with BV that vaginally applied probiotic species L. rhamnosus once a week over 6 months had significantly higher rate of vaginal microbiome recovery at both 6 months and 12 month follow up point. A group that was on metronidazole treatment had a significantly higher number of those found with abnormal flora at 12 months13.
      • Yeast infections or Thrush (VVC) - Another study showed that women that suffered from VVC (yeast / candida) infections and were treated with Fluconasole and probiotic strains Lactobacillus rhamnosus, GR-1® and Lactobacillus reuteri, RC-14® had significantly less Candida (18%) than women that were on Fluconasole treatment only (40%)14.

      So, how do probiotics work to help? 

      • Recolonising the vagina with healthy bacteria and restoring a healthy vaginal microbiome. A well formulated vaginal probiotic will boost healthy bacteria. Colonies of healthy bugs can help fight the bad bugs. However, there have been a great deal of failures in this department. Some scientists attempted to do so but good bugs failed to recolonize vagina, simply because they were using wrong lactobacillus strains. A simple application of probiotic species orally or intravaginally is not good enough and not all lactobacillus species have the same adherence abilities. This means that there was no ability for the good bugs to grow, thrive and stick around to fight off the bad bacteria.

        It was found that Lactobacillus crispatus, which is also known as the ‘super hero of the vagina’ colonized for over 8 months in 8x more female subjects compared with other lactobacillus species (40% vs 5%)15. This demonstrates that L. crispatus has superior adherence abilities compared with other good bugs.
      • Anti-biofilm properties. Biofilm is a matrix made by bacteria themselves. Think of it like a protective layer which surrounds and encloses clusters of bacteria and attaches itself to a body surface. Bad bugs are known to form biofilms in order to protect themselves from the adverse environmental conditions. Certain probiotics have the ability to disrupt bad bugs’ biofilm formations and expose bacteria to the influence of antimicrobial agents. It was found that healthy bacteria strains Lactobacillus rhamnosus, GR-1® and Lactobacillus reuteri, RC-14® have the ability to penetrate into the biofilms created by Gardnerella vaginalis and Atopobium vaginae and cause disruption of the biofilm, some even killing the bad bacteria independently16.
      • Lactic acid and other antimicrobial agent secretion. Lactic acid is a naturally occurring acid that helps keeps the vaginal microbiome healthy. Healthy Lactobacillus species secrete lactic acid which can kill bad bacteria by direct contact. Certain L. crispatus and L. gasseri strains have the remarkable ability to produce and release antibiotic-like compounds that help to fight bad bacteria17. These compounds were proven efficient against G. vaginalis and uropathogenic E. coli and can even cross the cell membrane and kill the pre-internalized microbial pathogens.

      There are also ways to make lifestyle changes to help avoid contact with bad bacteria that you can implement, like using condoms, avoiding douching and, if prescribed them, using the full course of antibiotics your doctor has prescribed even after symptoms have diminished. Plus if you have a regular partner, and you’re prone to reinfection, they may need to be treated at the same time as you.

      If you are experiencing symptoms, go to your medical professional and get tested before self-medication.

      Back to blog

      References

      See list of references used on this page

      1  Wilson J. Managing recurrent bacterial vaginosis. Sexually Transmitted Infections 2004;80:8-11.

      2 Bradshaw CS, Tabrizi SN, Fairley CK, Morton AN, Rudland E, Garland SM. The association of Atopobium vaginae and Gardnerella vaginalis with bacterial vaginosis and recurrence after oral metronidazole therapy. J Infect Dis. 2006 Sep 15;194(6):828-36.

      3 Larsson PG, Brandsborg E, Forsum U, Pendharkar S, Andersen KK, Nasic S, Hammarström L, Marcotte H. Extended antimicrobial treatment of bacterial vaginosis combined with human lactobacilli to find the best treatment and minimize the risk of relapses. BMC Infect Dis. 2011 Aug 19;11:223.

      4 Rosati D, Bruno M, Jaeger M, Ten Oever J, Netea MG. Recurrent Vulvovaginal Candidiasis: An Immunological Perspective. Microorganisms. 2020 Jan 21;8(2):144.

      5 De Backer E, Verhelst R, Verstraelen H, Claeys G, Verschraegen G, Temmerman M, Vaneechoutte M. Antibiotic susceptibility of Atopobium vaginae. BMC Infect Dis. 2006 Mar 16;6:51.

      6 Swidsinski A, Mendling W, Loening-Baucke V, Swidsinski S, Dörffel Y, Scholze J, Lochs H, Verstraelen H. An adherent Gardnerella vaginalis biofilm persists on the vaginal epithelium after standard therapy with oral metronidazole. Am J Obstet Gynecol. 2008 Jan;198(1):97.e1-6.

      7 Boris J, Pahlson C, Larsson P-G. Six-year follow-up after successful treatment of bacterial vaginosis. Int J STD AIDS1997;8(Suppl 1):41.

      8 Bradshaw CS, Morton AN, Hocking J, Garland SM, Morris MB, Moss LM, Horvath LB, Kuzevska I, Fairley CK. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis. 2006 Jun 1;193(11):1478-86.

      9 Bradshaw CS, Vodstrcil LA, Hocking JS, Law M, Pirotta M, Garland SM, De Guingand D, Morton AN, Fairley CK. Recurrence of bacterial vaginosis is significantly associated with posttreatment sexual activities and hormonal contraceptive use. Clin Infect Dis. 2013 Mar;56(6):777-86.

      10 Faught BM, Reyes S. Characterization and Treatment of Recurrent Bacterial Vaginosis. J Womens Health (Larchmt). 2019 Sep;28(9):1218-1226.

      11 Farr A, Effendy I, Frey Tirri B, Hof H, Mayser P, Petricevic L, Ruhnke M, Schaller M, Schaefer APA, Sustr V, Willinger B, Mendling W. Guideline: Vulvovaginal candidosis (AWMF 015/072, level S2k). Mycoses. 2021 Jun;64(6):583-602.

      12 Homayouni A, Bastani P, Ziyadi S, Mohammad-Alizadeh-Charandabi S, Ghalibaf M, Mortazavian AM, Mehrabany EV. Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Low Genit Tract Dis. 2014 Jan;18(1):79-86.

      13 Marcone V, Rocca G, Lichtner M, Calzolari E. Long-term vaginal administration of Lactobacillus rhamnosus as a complementary approach to management of bacterial vaginosis. Int J Gynaecol Obstet. 2010 Sep;110(3):223-6.

      14 Martinez RC, Franceschini SA, Patta MC, Quintana SM, Candido RC, Ferreira JC, De Martinis EC, Reid G. Improved treatment of vulvovaginal candidiasis with fluconazole plus probiotic Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14. Lett Appl Microbiol. 2009 Mar;48(3):269-74.

      15 Vallor AC, Antonio MA, Hawes SE, Hillier SL. Factors associated with acquisition of, or persistent colonization by, vaginal lactobacilli: role of hydrogen peroxide production. J Infect Dis. 2001 Dec 1;184(11):1431-6.

      16 McMillan A, Dell M, Zellar MP, Cribby S, Martz S, Hong E, Fu J, Abbas A, Dang T, Miller W, Reid G. Disruption of urogenital biofilms by lactobacilli. Colloids Surf B Biointerfaces. 2011 Aug 1;86(1):58-64.

      17 Atassi F, Pho Viet Ahn DL, Lievin-Le Moal V. Diverse Expression of Antimicrobial Activities Against Bacterial Vaginosis and Urinary Tract Infection Pathogens by Cervicovaginal Microbiota Strains of Lactobacillus gasseri and Lactobacillus crispatus. Front Microbiol. 2019 Dec 20;10:2900.