5 things to know about diabetes and vulvovaginal candidiasis

Women with diabetes have up to double the rates of colonisation with candida.

1. Vaginal candida colonisation is common 

VAGINAL colonisation with a candida species is common, occurring in over 20% of healthy asymptomatic women.

Women with diabetes have higher rates of colonisation, with reports of up to double that of women without diabetes.1 

With significant rates of candida colonisation in the general population, it is not surprising that 70–75% of women will experience vulvovaginal candidiasis in their lifetime. 

Up to 50% of these women will have at least one recurrence. 

2. Poorly managed and undiagnosed diabetes may predispose to symptomatic vaginitis. 

Diabetes mellitus is a known risk for vulvovaginal candidiasis. 

Due to the state of relative immuno­compromise, it is not surprising that subjects with abnormal HbA1c may experience more frequent symptomatology compared to those who are well managed and those without diabetes.1,2,4

Certainly the higher rates of colonisation in women with diabetes may play a role. 

3. In well-managed diabetes, it is unclear whether women experience more recurrent vulvovaginal candidiasis compared to women without diabetes.

Whether diabetes leads to more recurrent episodes of vulvovaginal candidiasis is an area of controversy, with study results both for and against. Recurrent, intractable candidiasis is reported in approximately 5% of all women.

While Candida albicans is responsible for more than 85% of candida vaginitis, non-albicans species may be detected in recurrent infection.3 

Non-albicans species such as C. glabrata are associated with treatment failure and therefore need to be identified. 

4. Non-albicans species are more common in women with diabetes.

Reports suggest that vulvovaginal candidiasis in women with diabetes is more likely to be caused by non-albicans species compared to those without.1,2 

The non-albicans candida, including C. glabrata, C. tropicalis and C. krusei, may have limited response to standard azole therapy and require an alternative treatment protocol.

While fluconazole 150mg as a single dose may elicit a response in some women, others may require induction followed by six months of maintenance treatment.5

Several regimens have been suggested, however all have significant recurrence rates, and vaginal culture is required at the completion of maintenance.6

Fluconazole 150mg daily for three days + maintenance or ketoconazole 400mg daily for 14 days + maintenance or boric acid pessaries (compounded 600mg boric acid in a gelatin capsule) 1 nocte for 14 days + maintenance or nystatin pessaries for 14 days + maintenance.

Maintenance therapy:

Oral – ketoconazole 100mg daily, itraconazole 50–100mg daily, fluconazole 100mg weekly or 150mg monthly. 

Topical – clotrimazole 500mg pessaries weekly or miconazole 100mg pessaries twice weekly for three months then once weekly for three months. 

5. Glucose tolerance testing is not routinely indicated in premenopausal women with recurrent vulvovaginal candidiasis.

While abnormal HbA1c is associated with symptomatic vulvovaginal candidiasis, there are many other associated factors such as antibiotic use, pregnancy, oral contraception and steroid treatment.7,8

The yield of routine glucose tolerance testing in all premenopausal women with recurrent vulvovaginal candidiasis is extremely low and therefore not justifiable. Similarly, for the most part, dietary restrictions are unnecessary in healthy subjects.