If you pick up a GYN textbook the section on candida vaginitis, i.e. yeast infections, will undoubtedly begin with a description of the supposedly classic symptom of a chunky white discharge (which does sound a bit like a punk rock band name). Ask almost any gynecologist who hasn’t been trained by me and you will get that same answer.

Here’s the news flash, science says it isn’t. Chunky white discharge being synonymous with yeast is something someone once wrote in a textbook and the myth was perpetuated over and over again until it became accepted as fact by providers and patients alike.

One housekeeping point. When I write posts like this I invariably get nasty comments from women or sometimes even doctors telling me I’m wrong/stupid/don’t know their body/asking if I am a real doctor. Those comments will not be accepted because it will be clear that you have not read the post, that you are rude, or both. The point of this post is to explain how everyone who thinks a chunky white = yeast has been duped.

Several studies have actually looked at the symptom of vaginal discharge to see if it is predictive of yeast (or other causes of vaginal irritation). In one study only 14% of women presenting with abnormal vaginal discharge and 16% with a change in discharge had a yeast infection. Another study found the symptom of troublesome vaginal discharge no more common among women with yeast versus other conditions and only 15% of women eventually diagnosed with Candida albicans (the #1 cause of yeast infections) reported bothersome discharge. One study even specifically asked women about the symptom of a “thick, curdy vaginal discharge.” It was reported by 16% of women who were culture positive for yeast and 13.5% who were culture negative (the difference was not statistically significant).

Many researchers have looked at diagnosing vaginitis over the telephone and time and time again they fail. It’s easier to rule things out over the phone but much harder to diagnose. ACOG actually advises against over the phone diagnosis of vaginitis (Practice Bulletin Number 72, May 2006) stating, “Whenever possible, patients requesting treatment by telephone should be asked to come in for an evaluation.” This is because symptoms, like the presence of absence of discharge, are not reliable predictors of much.

What about the discharge a doctor sees when they put in a speculum? There are no studies that demonstrate any correlation between the appearance of vaginal discharge on exam and whether a patient has yeast. In one study only 29%, so less than one-third, of women with a curdy white discharge on physical exam had a positive cultures for candida. Put another way if your doctor uses the presence of a curdy white discharge in the vagina to diagnose a yeast infection they are misdiagnosing 71% of women. That is far worse than flipping a coin. I don’t know about you but I expect a better diagnostic accuracy.

Vaginitis is misdiagnosed more often that not at home. In fact 70% of women who self-diagnose with yeast are incorrect. This is likely in part because women have been given incorrect information about discharge from their mothers and friends, from society, and from their health care providers. If every time you had a curdy, white discharge your doctor diagnosed you with yeast you would obviously think the two were related!

However, more and more it seems that women are astounded when I tell them clear/white/off white discharge is normal and that sometimes it will be heavier than others. If you remove your pubic hair you may more discharge on your underwear because there is no hair to trap it and there can be more friction on the vulvar skin without hair. Remember, discharge in underwear is both vaginal and vulvar in origin. If you don’t have itch, irritation or pain with sex or an odor and the discharge isn’t yellow or green or bloody I usually say give it a few days (unless of course there is a concern about sexually transmitted infections).

A lot of doctors admittedly do a bad job with vaginitis. Some diagnose patients based on what the discharge looks like (you can’t) and others fail to do all the tests. Others were improperly trained in looking at discharge under the microscope. This is a country-wide phenomenon and opinion pieces have been written lamenting the modern gynecologist’s inability to correctly diagnose vaginitis.

Vaginitis can also be complicated. Women can have yeast and it not be the cause of their symptoms, just like people can have an abnormal MRI and have no back pain. If the treatment takes away the yeast but not the symptoms then the yeast was not the cause. This is why follow-up is important and cultures offer more precision. If you think you are suffering from recurrent yeast you need a cuture as 2/3 of women diagnosed with “chronic vaginal yeast” have negative cultures and thus have something else.

If there is a dramatic change in the amount of discharge it is probably worth checking out, but keep in mind many things affect discharge such as changes in the good bacteria, how often you are having sex, and hormones just to name a few. The more sex you have, the more cells you shed (friction) and cells are a big part of discharge. Also, if you aren’t using condoms ejaculate hangs around (I can often find sperm under the microscope 2-3 days later) adding to the discharge.

Concerning vaginal symptoms are:

Genital itch

Genital irritation

Pain with sex

Odor

Yellow discharge

Green discharge

Bleeding discharge

Profuse discharge

I have seen all of these symptoms among women with yeast and among women with other conditions, the overlap is huge that is why an exam and work up are required.

Here is the truth, sometimes women have a chunky white discharge and sometimes they don’t. When it is present it is not usually a sign of much, especially not a yeast infection.

References:

Allen-Davis et. Al. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002;99:18-22. ACOG Practice Bulletin, Vaginitis Number 72, May 2006. Sobel J. Vulvovaginal candidiasis. Lancet 2007;369:1961-1971. Landers et al Predictive Value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol 2004:190;1004-1010. Goldacre MJ et al Vaginal Microbial flora in normal young women Br Med J. 1979 Jun 2;1(6176):1450-3. Beigi et al. Vaginal Yeast Colonization in Nonpregnant women: a longitudinal study. Obstet Gynecol 2004;104:926-930. Hoffstetter S et al. Telephone Triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms J Low Genit Tract Dis 2012;16:251-255. Erdem H. et al. Identification of yeasts in public hospital primary care patients with or without clinical vaginitis. Aust N Z J Obstet Gynecol 2003;43:312-316. Ferris DG et al. Over-the-counter antifungal drug misuse associated with patient-diagnosed candidiasis. Obstet Gynecol 2002;99:419-425.