Every GP knows the pattern. A patient comes in with something straightforward, maybe a cough, a rash, or a sore knee. We chat, make a plan – and just as the consultation is ending and the patient’s hand reaches the door handle, they pause and say the famous words: ‘Actually, doctor… there’s one more thing.’
When that ‘one more thing’ is delivered in a slightly quieter voice and accompanied by a look that suggests they would rather discuss almost anything else, very often it turns out to be a problem ‘down there’.
In particular, I frequently see patients complaining about recurring thrush or bacterial vaginosis (BV), two extremely common conditions that cause women a surprising amount of misery, frustration and Googling at 2am.
Many patients feel awkward bringing up their symptoms. These include unusual vaginal discharge, itching or burning and pain during sex or when urinating.
Usually, it’s the consistency of the discharge that is a clear indicator of thrush or BV. With BV, it is typically thin and watery with a distinct fishy smell, while with thrush the discharge is thick and cottage cheese–like.
But the truth is, vaginal infections are one of the most routine things we see in general practice. Trust me, no GP has ever fallen off their chair in shock when someone mentions an ‘itchy vagina’.
The difficulty is that thrush and BV can feel quite similar, which means they are often confused.
This can be problematic, as many women will seek over-the-counter treatment and may end up taking the wrong medication. This can prolong symptoms and, in some cases, make the condition worse.
Dr Raj Arora (pictured on ITV’s This Morning) says that when patients sheepishly ask her to discuss ‘one more thing’, it often tends to be about a problem ‘down there’
Thrush is caused by a yeast called Candida. Before you panic at the word ‘yeast,’ it is worth saying that Candida normally lives quite happily on our skin and in the vagina without causing any trouble at all.
Problems start when it decides to multiply like an overenthusiastic sourdough starter.
The result is the classic thrush symptoms: itching, soreness and a thick, white discharge. Some women also notice burning when passing urine or discomfort during sex. Not exactly a recipe for a good week.
BV is completely different: it is not caused by yeast, but by a change in the balance of bacteria in the vagina.
The vagina naturally contains lots of helpful bacteria, particularly Lactobacilli, which keep things slightly acidic and stop less friendly microbes from taking over. Think of them as tiny microscopic security guards.
If that balance gets disrupted, other bacteria can overgrow – and that is when BV appears.
Patients often describe a thin grey or white discharge with a distinctly fishy odour, which tends to be more noticeable after sex.
Unlike thrush, itching is usually not the main symptom.
Now here is where things get particularly annoying: both conditions have a habit of coming back. This may be because they are treated incorrectly or incompletely, but also because some individuals are more prone to recurrent infections.
Recurrent thrush, usually defined as four or more episodes a year, is incredibly frustrating. Many women feel like they are stuck in a never-ending cycle of treatment, brief relief, and the symptoms returning just as life is getting comfortable again.
There are several common triggers for both infection and reinfection. Antibiotics are a big one as, while they are excellent at killing harmful bacteria, they can also wipe out helpful bacteria – including those in your vagina that keep yeast under control.
Thrush is caused by yeast, resulting in itching, soreness and a thick, white discharge, whereas BV is not caused by yeast, but by a change in the balance of bacteria in the vagina
Dr Arora, a frequent guest on This Morning (pictured next to Dr Zoe Williams), says that thrush can be treated with antifungal medication, while antibiotics are best for BV
Hormonal changes can also play a role. Pregnancy, certain contraceptive pills and even fluctuations during the menstrual cycle can make thrush more likely.
Diabetes can increase the risk too, because higher sugar levels create a more yeast-friendly environment.
Tight, non-breathable underwear can sometimes contribute – although this is probably less dramatic than the internet would have you believe.
BV can also be stubbornly recurrent, but the causes are a bit different.
While not technically a sexually transmitted infection, sexual activity can influence the balance of vaginal bacteria and lead to BV. New partners, multiple partners and even semen (which is more alkaline), can temporarily shift the vaginal environment.
Then there are the well-intentioned habits that accidentally make things worse.
Vaginal douching, heavily perfumed soaps, and ‘intimate washes’ are frequent offenders. We can also add lubricants to this list, as these can alter the delicate pH of the vagina and leave it more prone to infections such as BV or thrush.
Ironically, many of these products are marketed as ways to keep the vagina fresh and healthy. In reality, the vagina is perfectly capable of doing that job on its own and generally prefers to be left alone.
Treatment depends on which condition you are dealing with.
Thrush is usually treated with antifungal medication, often available over-the-counter, and these treatments work very quickly for occasional infections.
If thrush keeps coming back, we sometimes use a longer prescribed treatment course over several months to break the cycle.
BV is treated differently, usually with antibiotics such as metronidazole, which can be taken as tablets or used as a vaginal gel.
Alongside medication, a few simple habits can help reduce the risk of recurrence for both infections.
Avoiding scented soaps, bubble baths and vaginal deodorants is a good start. Plain water or a gentle, non-perfumed cleanser is usually more than enough.
Cotton underwear tends to be kinder than tight synthetic fabrics, and changing out of sweaty gym clothes promptly can help, too.
Perhaps the most important point is this: if symptoms keep coming back, it is worth getting checked properly.
Many women assume any vaginal irritation must be thrush and repeatedly treat themselves with over-the-counter antifungals.
But in my clinic, I often see patients who have been treating ‘thrush’ for months when the real culprit was BV, or occasionally something else entirely.
The good news is that both conditions are treatable, and once the cause has been confirmed, we can use vaginal swabs if needed, things usually improve quickly.
So if you are stuck in the cycle of itch, irritation and late-night pharmacy runs, do not suffer in silence.
- Dr Arora is an NHS GP based in Surrey.
- Instagram: @dr_rajarora; TikTok: @drrajarora
