Recurrent thrush and UTIs
When repeat prescriptions stop working — and what the trials show
Recurrent vulvovaginal candidiasis means three or more symptomatic episodes in a year, affecting 5–8% of reproductive-age women. Guidance is to remove reversible drivers first — glycaemic control, antibiotic stewardship, contraceptive method, immunosuppression — before escalating antifungals.
Repeat empiric fluconazole is a common trap: cumulative exposure drives resistance, and non-albicans species (often intrinsically azole-resistant) are rising. If treatment keeps failing, ask for speciation rather than another identical course. Intravaginal boric acid is a recognized second-line option for non-albicans species.
On D-mannose for recurrent UTI: a 598-woman randomized trial found 51.0% on daily D-mannose had a UTI over six months versus 55.7% on placebo — no meaningful difference — and concluded it should not be recommended for prevention (JAMA Internal Medicine 2024). In postmenopausal women it added nothing beyond vaginal estrogen, which is the intervention that actually works in that group.
- Recurrent thrush
- 3+ episodes in a year; 5–8% of women
- Azole resistance
- Rises with repeat exposure
- D-mannose
- No benefit in a 598-woman RCT
- Non-albicans
- Often azole-resistant