Dr. Stephanie Arnold's patient was so uncomfortable she asked for a same day appointment. The suspect: a vaginal yeast infection. But there was some mystery, too. The patient had used a one-day, over-the-counter treatment for the problem. Why was she still in pain a week later?
Arnold examined her patient, took a swab to look at under the microscope and found no evidence of yeast or bacteria.
“I think it’s chemical irritation,” Arnold explained to her patient back in the exam room. The medicine, she explained, may have cleared the infection but made the burning feelings worse.
Yeast infections, or vulvovaginal candidiasis, are responsible for 1.4 million outpatient visits per year, and the cost of treatment is an estimated $368 million annually. They are extremely common – approximately 70% of women will have at least one yeast infection during their reproductive years.
3 choices
Patients at the pharmacy looking for relief usually find three options of a topical antifungal medication called miconazole — a 7-day version, a 3-day version and a 1-day version. The 7-day version has 100 mg of the active ingredient. The 1-day version has 1,200 mg. The most common brand name is Monistat; there are many generic brands, too.
Dr. Brandye Wilson-Manigat, an OB-GYN in the Los Angeles area, says she’s seen many patients with the same complaint as Arnold’s patient.
“Typically, what I would see is patients coming in thinking that the medication didn't work because they were still having such significant symptoms of burning and irritation and even sometimes swelling,” she says.
She says when she examined these patients, she would often find the 1-day treatment had “worked” in the sense that there was no longer a yeast infection. “It was kind of like a contact dermatitis, where the treatment led to this kind of inflammatory response,” she says.
Irritation, burning
Treatment guidelines from the Centers for Disease Control and Prevention say any of the concentrations work equally well to clear yeast infections although “local burning or irritation might occur.”
Patients use more colorful language. One reddit thread is titled: “Monistat 1 Burning like the fire of a thousand suns.” A product review describes the feeling as “scorching hot lava.”
“There aren't any formal recommendations” on using one strength of treatment over another, Wilson-Manigat says. But she makes a point of talking to her patients who are on antibiotics or have another risk factor for getting yeast infections. “I would usually forewarn them and say, ‘Hey, if you're gonna use the over-the-counter medication, please don't get the 1-day — use the 7-day or the 3-day.’”
Prestige Brands, which distributes Monistat, declined to comment for this story.
Dr. Jen Gunter, a San Francisco Bay Area OB-GYN and author of The Vagina Bible, warns that these are anecdotes. “There are studies comparing the 1-day and 7-day Monistat head to head, and the outcomes from a side effect standpoint are the same,” she writes in an email to NPR.
She points out that there could be other explanations for more reports of problems from the 1-day version. “We don't know, for example, if women who pick a 1-day therapy have more inflammation, so any product would be more irritating,” Gunter notes. She adds that many patients misdiagnose themselves with yeast infections, so it could be that “they are irritated because they used the wrong therapy.” (An exam at a doctor’s office is the best way to make sure you’re treating the right thing.)
Despite the name, 1-day versions don’t necessarily solve the problem faster. Monistat 1’s patient information reads: “Most women get some improvement in 1 day and complete relief by 7 days.” In other words, the number in the name of the product describes how many ovules or applicators you use, not necessarily how quickly you get relief. According to the package inserts, it usually takes about a week to resolve no matter which version you use.
A pill option via prescription
There is an oral medication people can take to treat a yeast infection, instead. It’s a single pill, called fluconazole, known by the brand name Diflucan. It requires a prescription in the U.S., though not in Canada.
Dr. Libby Wetterer, assistant professor of family medicine at the University of Pennsylvania, prefers the oral option for her patients. She says the rationale for why it’s not over-the-counter is the same reason why antibiotics aren’t over the counter — there’s a concern it would be overused and lead to drug-resistant microbes.
Wetterer tries to just make getting the pill as easy as possible for her patients. “If a patient's irritated and they've had a history of yeast infection and they message me saying, ‘I think I have a yeast infection,’ I would trust the person in their body and send them that prescription, often without seeing them,” she says, noting that not all physicians work that way.
For the patient in Richmond who was suffering from the yeast infection topical treatment, Dr. Stephanie Arnold prescribed a steroid cream. “This will help calm things down,“ Arnold told her, suggesting she keep the cream in the refrigerator for a little extra relief.
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