Interviews were conducted with 32 patients self-identifying with recurrent thrush (May 2022–June 2023) and 25 primary care or sexual health professionals (May–July 2024). Patient interviews lasted 45–90 min; clinician interviews 30–60 min. Demographic information can be found in Supplementary Boxes S1 and S2. Pseudonyms were used throughout: patients were invited to use an alias or their first names; while healthcare professionals were labelled with an initial and their job role.
Below we present three key themes illustrating areas where the needs of people with recurrent vulvovaginal thrush diverged from acute cases:
Navigating disjointed health services
Patient and healthcare professionals agreed that acute, transient, and one-off cases of thrush could be self-managed effectively through pharmacy care. Although there was recognition that pathways for recurrence needed to be different from those based on acute symptoms, transitioning between these and recognising when to do so was challenging.
Participants held various views on where recurrent thrush could be best managed and felt that signposting led patents in multiple, sometimes diverging, directions. Identifying, understanding, and knowing which services to see, and how often, was described as opaque and difficult to navigate. Patients expressed feeling caught in a void between services without a clear pathway.
‘The thing is with the chemist, if they say to you, “Oh, how many episodes of thrush have you had in [the] past so many months?” and I’m honest, they won’t give [medication] to me, they’ll say, “You’ve got to go to your GP”, well then, your GP will say to go to the pharmacy.’ (Leah, 26 years, woman, patient)
‘Every time that [thrush] came back, when I went to the pharmacy, or made a GP appointment, I was like is this the right level of concern?’ (Rowan, 24 years, woman, patient)
Healthcare professionals across general practice and sexual health clinics held differing opinions about which services were best suited to manage recurrent thrush. These viewpoints were influenced by regional differences in commissioning, resources, and accessibility of services. In some centres, sexual health services were able, allowed, and financed to provide care for recurrent thrush, with some offering specialist vulval clinics within genitourinary medicine (GUM) departments. In other regions, general practice was seen as the most appropriate avenue.
‘The biggest challenge is that patients don’t know where to go and there is nowhere for them to go, properly. […] [At our sexual health clinic] we are not supposed to see these patients. We are supposed to say, go back to your GP. [… ] I’ve masses of respect for GPs, but, sexual health doctors are trained in management of this sort of condition. There isn’t any joined up commissioning.’ (Dr O, 47 years, woman, Sexual health [SH] consultant)
Gaps in information sharing and communication across services were identified as an additional barrier to recognising a transition from acute episodes to recurrent thrush:
‘You aren't necessarily seeing the same GP each time, maybe not even a GP, you could go to the pharmacy, a nurse practitioner, maybe [a] sexual health [clinic]. We can't see sexual health notes. From general practice, we have this blindside.’ (Dr X, 40 years, woman, GP working in community gynaecology)
Patients with underlying conditions that can exacerbate recurrent thrush, such as HIV or diabetes, also faced challenges with knowing where to access collaborative care. For instance, Joy (43 years, woman, patient) said that her HIV team did not know much about recurrent thrush, and Teddy expressed confusion over what notes their diabetes team could access:
‘I assumed all my records would be together. I'm starting to think they're not.’ (Teddy, 21 years, non-binary, patient)
To address these challenges, some healthcare professionals tried to overcome silos and increase communication within and between sectors using written plans.
‘I’m a big believer in writing a plan so that other [clinicians] know what you were thinking, because I'd hate [the patient] to come back and then what I'd said was going to happen doesn't happen.’ (Dr Y, 59 years, woman, SH associate specialist)
Dr S (SH doctor, GP registrar) explained shared plans help create a ‘two-way system’ between sexual health clinicians and primary care professionals. Patients were also able to ask for their notes to be shared with them and bring those to their appointments to participate in collaborative plans. Within an overstretched health system, clinicians recognised that patients play an active role in coordinating and navigating their care journeys:
‘There’s a bit of fragmentation […] The person now that most notices the pattern, is the person experiencing the symptoms. If anyone in the system knows what’s going on, it’ll be the person. They’re the one unifying feature.’ (Dr A, 52 years, woman, GP partner)
Recurrent thrush was viewed as typically manageable within primary care or sexual health services, but unresponsive or evolving symptoms prompted consideration about referrals to secondary care. Some clinicians contacted gynaecology for advice or referrals, but others expressed hesitancy to place patients on long wait lists for gynaecology when the treatment options would not differ from those available in primary care. When other conditions were suspected with similar symptoms (for instance lichen sclerosus) referrals to vulval dermatology were seen as more appropriate.
Calls were made for more collaboration and clearer guidance within primary care regarding who should manage recurrent thrush (and in what order and which cases).
‘The expertise already exists, it doesn't have to be in a women’s health hub, but a clear system that everybody understands would be really helpful.’ (Dr O, 47 years, woman, SH consultant)
Recognising and responding to recurrence
When making decisions about how, when, and where to engage with health care, patients drew from past healthcare experiences as to whether they had felt the issue was (or would be) treated as ‘serious’. For patients, being taken ‘seriously’ in these cases often meant feeling that recurrent thrush was recognised as distinct from one-off cases, and necessitated a transition to different management and support:
‘I think the difference is how it impacts your life. Because if I had [thrush] once or twice, it would be uncomfortable, but when you get it recurrently, it’s a completely different condition. I think they should almost be treated completely separately and not related.’ (Harry, 25 years, woman, patient)
‘I think because [thrush] is common, [recurrent thrush] gets dismissed, it’s not seen as a serious health issue. I think we need to separate out those very common episodes from once it starts getting to be more recurrent.’ (Dr Y, 59 years, woman, SH associate specialist)
Although all cases of recurrent thrush will begin with a first episode, recognising the transition between one-off to ongoing helped recognise the distinct psychological impact and management challenges. A sexual health doctor reflected that while acute thrush was ‘quite easy’ to manage, recurrent thrush ‘needs a bit more thinking about’ (Dr E, SH doctor). A GP thought the impact on people’s body image and relationships made recurrent thrush ‘really complex for everybody’ (Dr K, GP).
Further tensions could arise when clinicians expressed caution around their language to avoid alarming patients, whereas patients worried that this meant their concerns were not taken seriously. For example, some clinicians weighed up referring patients to ‘complex’ sexual health or GUM clinic that could offer help for recurrent thrush, but were perceived as possibly causing alarm:
‘They’re then hearing the term that we have for the clinic, which is the “complex clinic”, that’s probably a bit daunting hearing that term. […] “But it’s not a complex... is this a complex issue?” so I imagine it can be quite confusing. (Dr F, 35 years, woman, GP)
Feeling taken ‘seriously’ also related to larger social narratives that framed recurrent thrush as something to tolerate. These accounts were rooted in participants’ own experiences, but also drew on social conversations about gender health inequities. Recurrent thrush was framed as a ‘woman’s issue’, which had an impact on how participants (including cis-women, trans, non-binary, and gender fluid people) understood the condition. Teddy who is non-binary, and KJ who is gender fluid, said people with vaginas were told to expect discomfort, ‘tough it out’, or ‘soldier on’. Many clinicians raised concern over these gendered narratives, as one GP said that recurrent thrush was ‘wrongly minimised because of the perception that “oh it’s a women’s issue so it’s a minor thing”.’
When a clinician was able to communicate that recurrent thrush required a distinct approach, plan, and validation of its impact, patients felt more able to return to seek care:
‘I remember doctors not seeming that concerned or interested, until I saw this amazing doctor. He was really listening and took it really seriously. He was like, “This is really serious, I'm so glad you've ended up here”.’ (Anna, 34 years, woman, patient)
Patients also felt recurrence was recognised when they were prescribed longer-term treatment plans instead of advice and medication suited for a one-off thrush episode:
‘I had a really positive experience initially with the GP who took it quite seriously and gave me 6 months’ worth of capsules to take once a week.’ (Julia,36 years, woman, patient)
Building ongoing healthcare relationships
Recurrent thrush necessitated repeated care, which meant that ongoing and enduring relationships with healthcare professionals were important. An ongoing relationship with a healthcare professional enabled monitoring progress and changes over time. Patients found it difficult to see a different clinician each time and re-explain their experience:
‘I’m lucky that I have a very good relationship with my GP. Now that this has happened in the past, I am kind of confident that I’d be listened to and it wouldn’t be minimised.’ (Rowan, 24 years, woman, patient)
Managing expectations was also central to building ongoing relationships. During early consultations, patients anticipated a ‘quick fix’, or ‘cure’. Over time, they transitioned to see recurrent thrush as requiring ongoing management. By presenting a plan for follow-up, patients felt heard and healthcare professionals were able to gain trust towards managing this condition:
‘I say, “I am going to help you, but you need to persist with me …” I say you must come back to me at this time and we will review it again, and this will be the plan. Then they’ll trust you. Even if they have a blip, they’ll still trust you. The plan is sound.’ (Dr Y, 59 years, woman, SH associate specialist)
Trust was a critical factor in patients feeling able to return to seek care. Patients and clinicians agreed that trusting relationships were shaken through small acts, such as missing follow-up phone calls, losing samples, and not planning next steps.
Some healthcare professionals noted that saying “please come back” was often not enough when patients were unsure whether recurrent thrush warranted further attention or whether they may get lost in a disjointed system. A sexual health doctor (Dr L, SH doctor) tried to establish trust with patients by saying: ‘you are not on your own’ and approach longer-term treatment as ‘we’re doing this together, teamwork’. Dr E (SH) explained their approach to continuity of care:
‘[In] sexual health services, if they see me one week, I can easily put them into my clinic list two weeks later, and three weeks later, a month later.’ (Dr E, 34 years, man, SH doctor)
However, other clinicians did not (or could not) routinely offer follow-up appointments, rather encouraging patients to return if symptoms did not resolve:
‘I don’t think I’ve ever seen a thrush patient and said, “I think we need to see you again in a few weeks to see how you’re getting on – let me book you in.” I’ve probably just said, “If things aren’t improving, or your symptoms change, please come back” and left the ball in their court.’ (Ms I, 35 years, woman, physician associate)
Some patients found that learning more about health services and systems (whether through repeat appointments, support groups, social media, or research) helped them gain confidence in self-advocating. This included feeling more able to ask questions and request additional appointments. Self-advocacy was framed as enabling conversations around collaborative care:
‘It’s really hard to sit in front of a doctor and go, “I don't agree with you”, but it might make them question it and go, “oh right, OK, if you don’t agree, how can we work together to sort it out?”.’ (Billie, 25 years, woman, patient)
However, some patients reported frustration growing over time or feeling unable to self-advocate, and clinicians recognised these limitations:
‘There’s loads of barriers and taboos around women’s health. Some they’re very determined they will keep going back to the doctor, those patients I’m not worried about, but the patients who have language barriers, or who have access issues, those ones I’m concerned about.’ (Dr F, 35 years, woman, GP)
Building ongoing healthcare relationships was not always straightforward or linear, but once established provided a valued space for collaborative care and informational continuity.
