Topical Treatments for Vaginal Yeast Infections in Pregnancy and Lactation
This health topic is an expert opinion about treating vaginal yeast infections with topical antifungals during pregnancy and lactation.
*The information provided is the expert opinion of the First Exposure Medical Advisors. It is for informational purposes only and does not replace medical care and advice from a healthcare provider. Please contact your healthcare provider if you have any concerns or to discuss any questions that you believe may be relevant to you or your baby. In case of emergency, please go to the emergency room or call 911
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Clinical Scenario:
I am prone to yeast infections. Am I able to use topical treatments during pregnancy or while nursing?
Q. What is a yeast infection?
A. Vaginal yeast infection (vulvovaginal candidiasis) is a common cause of vaginal itching, soreness, abnormal vaginal discharge, and pain during vaginal sex or urination. It affects approximately 3 out of every 4 women at least once in their lifetime. Infections are more common in pregnancy because the hormonal changes create an environment in which it is easy for yeast to grow. Candida (yeast) normally lives in the vagina without causing problems. When it grows too much it is called an infection. Vaginal yeast infection is not considered a sexually transmitted disease, however it can be transferred between sexual partners. Diagnosis typically involves gathering information on symptoms (history-taking), physical examination, and laboratory testing (i.e. vaginal swabs) to identify yeast. In pregnancy, it is recommended that those with vaginal symptoms be assessed by a healthcare professional to check for other causes and discuss treatment options.
Q. What are the most common treatments for yeast infections in pregnancy?
A. The first treatment usually used for treating symptomatic vaginal yeast infection is a topical antifungal drug (vaginal cream or vaginal ovules/suppositories). Topical antifungals available are miconazole, clotrimazole, and terconazole. In pregnancy, a seven-day treatment is recommended (instead of a shorter course) for better cure rates. Although most of these medications are available over-the-counter at pharmacies without a prescription, whenever possible, pregnant individuals should get medical advice before self-treating. Healthcare providers occasionally use other medications or additional treatments. This Health Topic will focus on topical antifungal use in pregnancy.
Q. Can topical antifungals be used while trying to get pregnant
A. Topical antifungals are not expected to make it harder to get pregnant.
Q. Does using topical antifungals in pregnancy increase the chance of a miscarriage?
A. Miscarriage occurs in approximately 15-20% of all pregnancies (1-in-5 pregnancies). Use of topical antifungals such miconazole/clotrimazole/terconazole have not been shown to increase the risk of miscarriage.
Q. Does using topical antifungals in pregnancy increase the chance of a birth defect?
A. The baseline risk of major birth defects in Canada is 3-5%. This means that 3-5 out of 100 babies born in the general population in Canada will be born with a major birth defect. Studies including several thousand pregnancies have shown that topical antifungals do not increase the risk of birth defects above the baseline risk.
Q. Does using topical antifungals in pregnancy increase the risk of any other harmful outcomes?
A. Topical antifungals like miconazole and clotrimazole have poor absorption and therefore only very small amounts get into the blood. There is no evidence indicating an increased risk of harm from use in pregnancy.
Q. Can topical antifungals be used while nursing?
A. Studies have not been done to assess drug levels in breast milk after use of topical antifungals. However, because topical antifungals like miconazole and clotrimazole have poor absorption from the skin and vagina, it is unlikely to enter breast milk in high amounts and cause harm to the infant.
Q. Are there ways to prevent vaginal yeast infections?
A. There is not enough information showing that avoiding tight fitted clothing or humid conditions, diet modifications, eating yogurt, probiotics, or changing out of wet garments will prevent a yeast infection. Douching is not recommended as it can destroy the helpful bacteria in the vagina that keep yeast under control.
Q. Advice for specific populations?
A. Some populations, such as those with weakened immunes systems (e.g. those living with HIV or poorly controlled diabetes) are more likely to develop yeast infections. As well, access to healthcare and treatment can vary widely among different populations, leading to disparities in the management of yeast infections in pregnancy. For example, people may have prior traumatic experiences, or for cultural reasons may be uncomfortable with a vaginal exam. Trauma aware and informed care and self-sampling (taking their own vaginal sample) may be helpful in these situations. Addressing equity issues requires efforts at multiple levels to ensure all pregnant individuals have access to appropriate care and treatment. 
Key References:
Clotrimazole (Topical) [Internet]. UpToDate, Inc. 2023 [cited August 18, 2023]. Available from: https://online.lexi.com.
Miconazole (Topical). [Internet]. UpToDate, Inc. [cited August 8, 2023]. Available from: https://online.lexi.com.
Aguin TJ, Sobel JD. Vulvovaginal candidiasis in pregnancy. Curr Infect Dis Rep. 2015;17(6):462.[PMID: 25916994].
Czeizel AE, Tóth M, Rockenbauer M. No teratogenic effect after clotrimazole therapy during pregnancy. Epidemiology. 1999;10(4):437-40.[PMID: 10401880].
Jaeger M, Plantinga TS, Joosten LA, Kullberg BJ, Netea MG. Genetic basis for recurrent vulvo-vaginal candidiasis. Curr Infect Dis Rep. 2013;15(2):136-42.[PMID: 23354953].
Office on Women’s Health. Vaginal yeast infections Washington, D.C.: U.S. Department of Health & Human Services; 2021 [cited 2023 August 18]. Available from: https://www.womenshealth.gov/a-z-topics/vaginal-yeast-infections#:~:text=Yeast%20infections%20are%20not%20STIs,who%20has%20a%20yeast%20infection
Rosa FW, Baum C, Shaw M. Pregnancy outcomes after first-trimester vaginitis drug therapy. Obstet Gynecol. 1987;69(5):751-5.[PMID: 3574801].
Sobel JD. Vulvovaginal candidosis. Lancet. 2007;369(9577):1961-71.[PMID: 17560449].
Young GL, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev. 2001(4):Cd000225.[PMID: 11687074].
Disclaimer
First Exposure does not offer health care treatment. If you have an urgent question about your pregnancy or your baby’s health, you should contact your health care provider directly. If you don’t have a health care provider and you live in Ontario, you have a variety of health care options. In the case of an emergency, visit a hospital emergency room or call 911.