Remember that treatment typically takes three months before a chronic vulvovaginal candidiasis (CVVC) patient is completely asymptomatic (1). It is a slow process, but there should be improvement over time. If the diagnosis is correct (based on signs and symptoms), then there is a very high success rate of complete symptom resolution (a 100% success rate in some studies!) (2).

If treatment fails after three months, then there are several possibilities (3):

• The diagnosis was incorrect, and other possibilities should be considered. See Box 3 in this research article for other causes of chronic vulvovaginitis.

• The diagnosis was correct but the presence of other conditions has prevented a complete symptom and pain resolution. This could include pelvic floor spasm or skin conditions. In these cases, patients are usually significantly improved but still have residual complaints (e.g., pain with penetrative sex).

• The candida is either resistant to the medication or requires a higher dose to be eradicated (e.g., 200mg instead of 100mg daily fluconazole).

• The medication is not being absorbed properly and a different medication may need to be used. In some cases, this may indicate celiac disease.

• If a woman is postmenopausal and taking estrogen replacement therapy, this can interfere with treatment. Estrogen replacement therapy may need to be stopped completely during treatment.