Vaginitis: common and annoying, but curable

Vaginitis: common and annoying, but curable – includes related information

Vaginitis: common and annoying, but curable

Vaginitis is a blanket term that lumps together several specific conditions that inflame the lower female genital tract. One of the most common disorders seen by family physicians and gynecologists, the complaint can affect women of all ages, even young girls and babies. With vaginitis, there’s often a discharge and the vagina may be inflamed and sore, a discomfort that can spread to the vulva (inner and outer folds of the external female genitalia — SEE DIAGRAM).

The vagina’s normal ecosystem

Most adult women have some normal vaginal discharge which fluctuates with age, the menstrual cycle, sexual activity, and stress. A normal vaginal discharge varies throughout the menstrual cycle, from clear and slippery to thick and sticky, often staining the underpants yellow. Some adult women experience a profuse, but quite normal vaginal flow, especially just before and during ovulation. Yet, often they (and their medical advisors) mistake a naturally copious flow for vaginitis. One U.S. survey showed that 10 per cent of women who complained of vaginitis were simply distressed by above average amounts of normal vaginal secretions.

Changes in vaginal discharge may reflect subtle alterations in the vagina’s natural ecosystem — in the balance of micro-organisms that normally inhabit its folds. Within the vagina’s ridged lining many bacteria and other organisms dwell in friendly co-existence (symbiosis). Changes in their relative numbers occur because of: fluctuations in estrogens and other hormones; varying levels of glycogen (a storage carbohydrate); the changes of puberty, pregnancy, or menopause; use of oral contraceptives and other drugs, especially antibiotics. The vaginal acidity or alkalinity (measured as “pH”) greatly influences vaginal discharge. The healthy vagina is acidic with a low pH ranging from 3.5 to 4.5 (a higher pH means a lower acidity). The vagina’s environment is kept acid by harmless lactobacilli — acid-producing bacteria living in harmony with other vaginal micro-organisms. By making the vagina acidic, lactobacilli keep harmful organisms in check. But in their absence, other infective organisms can flourish and irritate the vagina.

First alert: altered discharge, odour and irritation

The first signs of vaginitis are: an unusual vaginal discharge; a change in its odour; and perhaps some genital itching or soreness. The vaginal discharge may increase, change colour or be blood-tinged. Urination may be painful. Sometimes an unbearable itch sends a woman with vaginitis to see her physician, sometimes it’s an unusual discharge or unpleasant odour that is the driving force.

Tracking down the causes

The main causes of vaginitis are atrophy (vaginal thinking and dryness), mechanical problems (foreign objects in the vagina) and infections. But anything that disrupts the vagina’s normal ecosystem can trigger vaginitis. Some women have such delicately balanced vaginal ecosystems that even small, temporary changes in acidity can upset them. For instance, semen makes the vagina briefly alkaline for a few hours, generally not long enough to cause symptoms, although a few women complain of vaginitis following each coital act. The vagina’s ecosystem can also be upset by: douching, bits of tampon accidentally left in, or small objects pushed in by exploratory young girls. Medications that reduce lactobacilli numbers (such as steroids or some broad-spectrum antibiotics) may also set the stage for vaginitis.

Infective vaginitis is usually due to one of micro-organisms: mixed bacteria, including Gardnerella; Candida albicans (a yeast); and Trichomonas vaginalis or “trich” (a protozoan). Each type of vaginitis has distinct features, but several infections may co-exist (SEE TABLE). Occassionally symptoms similar to vaginitis arise from cervical infections (of the cervix or mouth of the womb) due to sexually transmitted diseases, such as chlamydia and gonorrhea.

Diagnosis the key to successful treatment

Despite the recognizably different forms of vaginitis, some physicians prescribe “shotgun” drug therapy, based merely on a patient’s vague description of symptoms, or on appearance alone, without a thorough examination. Sometimes treatment is even prescribed over the phone! A recent British survey found that only a third of patients given medication for a presumed yeast infection were examined. Physicians frequently failed to take smears or send samples for lab analysis, omitting the few tests that could quickly have pinpointed the cause. Some physicians evidently still prescribe creams, suppositories or tablets without targetting them to a specific agent.

Experts now believe that a few simple (office) tests are essential for a fast, effective cure of vaginal discomfort. Accurate diagnosis permits treatment geared to the offending causes.

Diagnosis involves a detailed history, examination of the discharge, a “whiff” or smell test, and, in many cases, lab culture of a swab (growing the organism). Very often a microscopic look at the discharge (“smear”/sample) plus a simple pH test is sufficient for diagnosis. Provided the right questions are asked and the right tests done, a physician can often tell what’s causing the vaginitis. For instance, those with candidiasis have acidic vaginal secretions; those with “trich” and/or mixed bacteria have a more alkaline discharge. Treatment is usually initiated after a thorough office examination, sometimes with a follow-up visit to make sure the chosen medication was correct (or if an adjustment is necessary). A cure may also demand treatment of sexual partner(s).

Bacterial vaginosis: typified by strong, fishly odour

Bacterial vaginosis (formerly called nonspecific or Gardnerella vaginosis) is due to several types of bacteria, including Gardnerella and “anaerobic” forms. Its hallmark is a runny, milky-grey discharge with a foul odour (worse at mid-cycle and post-coitally). The fishy odour can be cleary detected by the “whiff test” (adding potassium hydroxide to a sample of the discharge on a slide) giving clear pointers to the causative agents. IUDs may increase the risk of bacterial vaginosis. Trying to get rid of the odour with perfumes or douches only tends to worsen the condition!

The standard treatment for bacterial vaginosis is metronidazole (Flagyl), taken for seven days. Those on it should avoid alcoholic drinks until 24 hours after the last dose because with alcohol this drug causes nausea and vomiting. The medication should not be used during pregnancy (amoxicillin is an alternative). Occassionally, vaginal douching with dilute vinegar is prescribed to acidify the vagina.

Yeast moniliasis or candidiasis

As early as 400 B.C., Hippocrates noted yeast infections or “thrush”, as whitish patches on the gums and tongue. The yeast, Candida albicans, is a fungus that may also inhabit human intestines and vagina. Over 50 per cent of adult women suffer at least one attack of candida vaginitis, some suffering repeat episodes. Ordinarily harmless vaginal dwellers, candida yeasts produce vaginitis if the ecosystem is distrubed. The less acidic the vagina, the more prone it is to yeast infections. Candidiasis occurs most often in young women, less in post-menopausals (except in those on estrogen replacement therapy). But, contrary to popular belief — which blames yeasts for most vaginitis — these organisms only account for 25 to 30 per cent of Canadian vaginitis cases.

The telltale signs of vaginal candidiasis are: intense genital itching (often severe enough to hinder sleep); sore, swollen, possibly reddened labia; and a thick, white, curdy, cottage-cheese-like discharge. A few women with candidiasis report a yeasty odour like fermenting dough! There may be pain on intercourse and a burning sensation when urinating.

Several factors increase susceptibility to yeast infections, particularly pregnancy, prolonged antibiotic use and perhaps birth control pills (still debated). During pregnancy, vaginal yeasts increase because of decreased vaginal acidity and a higher output of female hormones which raise glycogen (carbohydrate) levels, favouring candidal growth. Poor ventillation in the genital area may exacerbate or perpetuate (but not cause) yeast infections. Tight underwear or jeans may trap the infection against the vulva. Other predisposing factors include: menopausal thinning of the vaginal wall; diabetes; cuts/abrasions in the genital area; poor hygiene (soiled underwear and transfer of fecal yeasts) and douching. Dietary sugar and a defect in milk sugar (lactose) metabolism may predispose some women to yeast infections. For them, eliminating dairy products from the diet and cutting down on sugar may help to curb candidiasis. While there’s no proof that diet alters susceptibility to vaginitis, abnormal carbohydrate metabolism (as in diabetes) can increase the sugar content of vaginal secretions. And since yeasts feed on sugar, conditions that raise vaginal glucose levels could promote their growth.

Effective treatment for candidiasis combines anti-fungals with good hygiene — wiping with toilet paper from front to back. Wearing loose cotton underwear may combat but not prevent a yeast infection. Antifungals for candidiasis include miconazole or Monistat, clotrimazole or Canesten and econazole or Ecostatin. Given as tablets, creams or suppositories they block fungal growth. Since many women stop taking the antifungals once symptoms vanish (although the yeasts may linger), a single-shot clotrimazole dose is effective and avoids non-compliance. A more recent antifungal, oral ketoconazole (Nizoral) is 90 per cent effective against severe candidiasis, but symptoms return if it’s discontinued and it requires close medical surveillance as it can damage the liver. It should never be used during pregnancy or when conception could occur. A trusted older remedy — Gentian violet — may still be worth a try, although it can produce allergies and is a bit messy! Betadine douches are sometimes prescribed for mild cases. Coitus and tampons are discouraged while treating vaginitis.

Although antifungals clear up 90 per cent of yeast vaginitis, in spite of eliminating all possible predisposing factors, such as antibiotic or oral contraceptive use, some women are plagued by repeat infections. Recurrent candidiasis is sometimes ascribed to self-reinfection, poor hygiene or individual sex habits (although no scientific data proves anal transmission). Applying antifungals to the entire genital area and scrupulous cleanliness may minimize recurrences. Antifungal-saturated tampons may reduce yeast infections in women prone to pre-menstrual flare-ups.

Occasionally, yeasts invade several organs and threaten health. But theories and claims — such as those proposed in The Missing Diagnosis and The Yeast Connection — that blame a wide gamut of illnesses on yeast overgrowth are totally unsubstantiated. Allegations that candidiasis has reached epidemic proportions owing to carbohydrate-rich diets, the Pill, pollution and repressed immune systems do not stand up to scientific scrutiny. The unspecific complaints attributed to Canada could arise from other causes. The Yeast Connection has been strongly attacked by organizations like the American Academy of Allergy and Immunology as “sheer speculation, without a shred of evidence”.

Trichomonal/protozoan vaginitis or “trich”

Trichomoniasis vaginalis (nicknamed “trich”), is due to a tiny, almond-shaped, unicellular parasite that often produces little or no discomfort. In symptom-free women, a “trich” infection may only be discovered during a routine gynecological examination or a “Pap smear”. In others, the infection causes vulvar irritation (less bothersome than with candidiasis), a greeny yellow, sometimes frothy discharge, possibly a bad smell. Urination may be painful. “Trich” infections, which thrive in a non-acidic vagina, are mostly sexually transmitted, with frequent ping pong reinfection between partners. But sexual contact isn’t the sole transmission route. “Trich” protozoa can survive outside the body for up to three hours and be spread in bubble baths, hot tubs, whirlpools and by wet towels or facecloths. Occasionally “trich” is found in prepubertal girls. In men it can produce prostatitis.

Diagnostic tests on the discharge usually reveal whip-tailed parasites under a microscope. Treatment is a single or seven-day course of metronidazole — for the patient and any sexual partner(s). Treating the sexual partner(s) is crucial to reduce the spread of “trich”. Metronidazole is not given to pregnant women, who should take alternative medication. (SEE TABLE)

Chlamydia — the silent epidemic

Besides vaginal infections, sexually transmitted diseases such as chlamydia and gonorrhea, which infect the cervix (mouth of uterus/womb) may produce symptoms similar to vaginitis. Chlamydia sometimes causes a vaginal discharge. It is now the most prevalent sexually transmitted disease (STD) in Canada, especially among sexually active 18- to 20-year-olds. With five times the incidence of gonorrhea, chlamydia has been dubbed “the sexually transmitted disease of the 80s”, or “the silent epidemic”, because it so often produces no symptoms. Many of those infected don’t seek treatment. In one study, 37 per cent of adolescents unknowingly carried chlamydia. Health and Welfare Canada statistics indicate that between 1983 and 1984 the number of chlamydia cases among 20- to 24-year-olds more than doubled with a six-fold increase in 15- to 19-year-olds. The numbers may be up because of newly available cheap and easy-to-do lab tests for chlamydia. Chlamydia can live undetected in the cervix for over a year. Any symptoms produced are usually mild — a discharge, burning on urination, perhaps abdominal pain. Left untreated, chlamydia may cause pelvic inflammatory disease (PID), leading to ectopic pregnancy and infertility. It can also cause conjunctivitis (eye inflammation). And during delivery chlamydia may infect newborn eyes or lungs. In men, chlamydia frequently causes urethritis (urinary tract inflammation) and prostate troubles. Chlamydial STD responds well to antibiotic treatment (SEE TABLE).

Gonorrhea (GC)

Gonorrhea, a sexually transmitted cervical infection due to Neisseria gonorrhoeae, is popularly called “the clap” — from the old French word for prostitutes (les clapiers). It is still common in Canada because of sexual permissiveness and the emergence of drug-resistant strains. Although symptomless in about 80 per cent of those infected, gonorrhea may produce lower abdominal pain and bloating, a brownish-yellow discharge, and painful urination. Its most serious complication, PID, can scar the fallopian tubes and cause infertility. If present during pregnancy, GC may trigger a miscarriage or premature membrane rupture. During labour, the newborn may get an eye infection (ophthalmia neonatorum) that can lead to blindness if not prevented at birth with appropriate eyedrops (silver nitrate or erythromycin). Antibiotic treatment for patient and sex partner(s) is the usual therapy. Properly used, condoms plus foam may prevent GC and also avoid other STDs, not to mention AIDS! Since both GC and chlamydia frequently show no sign of their presence, regular medical check-ups are a good idea for those at risk of STDs.

Non-infectious vaginitis

In young girls, vaginitis may arise from mechanical irritation, especially if childhood curiosity leads them to insert small objects into the vagina. Doctors have removed items ranging from toothpicks and matches to paperclips and stones from small vaginas! In preadolescents, atrophic vaginitis may occur because of low estrogen levels. In postmenopausal women, a thinned vaginal lining may crack, bleed, and become mildly infected. An estrogen-containing cream, applied locally, can offset some postmenopausal vaginal thinning, provided it’s not medically contraindicated.

Home remedies of dubious help

Trying to self-treat an undesirably copious vaginal discharge with non-prescription douches may only upset the vagina’s stable ecosystem. Douching isn’t generally recommended and douching solutions themselves can irritate the genitals. Self-care books often suggest the “natural” therapy of inserting yogurt into the vagina, the rationale being that it contains lactobacilli, which may help to re-establish the vagina’s normal acidity and deter other organisms. Although messy and of no proven benefit, the practice isn’t harmful!

The more scientific modern approach to vaginitis means that women need no longer suffer its discomforts. Some centres, such as those at a few University of Toronto teaching hospitals, have established women’s clinics to provide specialized care for vaginitis and other female disorders.

COPYRIGHT 1988 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group