Vaginitis

Author: Dr Paul Nadler University of California San Francisco 2008-07-22

Vaginitis: Vaginal Discharge from Yeast infections, Bacterial Infections, and Other Causes A common, bothersome, gynecological condition with multiple causes. This article will help a woman better understand vaginitis, and explain what symptoms can be treated at home, and when should she go in for an exam.

Vaginitis is a medical term for inflammation of the vagina. The usual symptoms are increased vaginal discharge (often with an unpleasant odor), itching of the labia and vulva, and irritation of the vagina.  In more severe cases, a woman may experience vaginal or pelvic pain, fever, and bleeding. 

Vaginitis is a common condition.  Most women successfully treat milder forms with over-the-counter medication.  But some types of vaginitis are caused by dangerous medical problems, and it is important for women to have the knowledge to distinguish the minor from the serious.  In the following discussion, common forms of vaginitis will be defined, and their treatment explained.

Normal Vaginal Health

The normal, healthy environment of the vagina is maintained by an abundant presence of bacteria called lactobacillus.  These do not cause symptoms, and they maintain a favorable pH (acidity).  Lactobacilli keep other harmful microorganisms, usually present in low numbers, in check.  Estrogen, a hormone produced in a woman’s ovaries, also promotes healthy vaginal tissue. 

Most women produce a small amount of normal vaginal discharge daily.  This consists of cells that are sloughed off when replaced by the body with new cells, cervical mucus, and vaginal secretions.  The amount of normal discharge will vary during the menstrual cycle as a woman’s estrogen level naturally rises and falls. It is often somewhat increased in women taking oral contraceptives containing estrogen. In post-menopausal women, the amount of vaginal discharge diminishes, as the ovaries no longer produce estrogen.

Changes that cause Vaginitis

If there is a decrease in the normal amount of lactobacilli present in a woman’s vagina, the amount, odor, or consistency of the vaginal discharge changes.  This happens because yeast or other troublesome bacteria, no longer kept in check by the lactobacilli, rapidly multiply.  A woman may also develop symptoms of itching or irritation. 

Vaginitis can also result from an infection acquired from sexual intercourse. Sexually transmitted infections are aggressive, and if not treated promptly, can cause a serious abdominal infection and permanent scarring that reduce fertility. 

It is also common to develop symptoms of vaginitis after menopause.  Without estrogen, the vaginal tissue can weaken and become dry.  These changes can cause irritation.

Fortunately, the cause of vaginitis can be accurately diagnosed and effectively treated in a clinician’s office.  Although in mild recurrent cases a woman can treat her own symptoms with over-the-counter medications, she should never hesitate to seek professional evaluation if the symptoms are new, unusual, or do not respond promptly to treatments that have worked before.  Also, if a woman develops uncomfortable vaginal symptoms after menopause, it should not be attributed to “just getting older.”  She should honestly discuss them with her clinician, as these problems are common and will respond well to treatment.

Types of Vaginitis

I.  Bacterial Vaginosis (also know as “BV”)

This is the most common cause of vaginal discharge in women of childbearing age.  It is NOT a sexually acquired infection. Rather, it results when troublesome bacteria that are normally present in the vagina in low numbers, increase in number to abnormally high levels.  Although the exact reason why the types of bacteria in the vagina change in number leading to disease, the following risk factors are associated with the developing BV.

Risk factors

1)    Multiple or new sexual partners.  Although bacterial vaginosis is not a sexually transmitted infection, women who have many (or new) sexual partners are at higher risk.  While sexual activity increases the risk of developing symptoms, BV is clearly not caused by sexual activity as some women who have never had sex develop BV.  Also, there is no benefit in treating the male partner of a woman who has bacterial vaginosis, even when if it recurs multiple times.

2)    Cigarette smoking.  BV occurs in smokers more often than non-smokers.
3)    Douching.  This is thought to reduce the protective benefit of lactobacilli bacteria in the vagina.
4)    Stress is a risk factor.

Risks of Untreated infection

Bacterial vaginosis causes unpleasant symptoms, and is implicated in some other significant health problems
1)    Women with BV have an increased chance of developing the sexually transmitted infections genital herpes, gonorrhea, chlamydia, and HIV.
2)    Pregnant women with BV are at higher risk of a pre-term delivery.  (There is no evidence, however, that testing for BV in a pregnant women with no symptoms of vaginitis is necessary)
3)    If a woman with BV has a hysterectomy or abortion, they run a higher risk of developing a surgical infection

Signs and Symptoms

Many and possibly most women with bacterial vaginosis have no symptoms.  The overgrowth of bacteria in these cases may be minor or self-limited (able to heal without treatment).  When symptoms do develop, a strong smelling (often described as “fishy smelling”) vaginal discharge develops.  The discharge is usually thin and grey. It is common for women to feel that the vulva is irritated, but it is usually not described as itchy. Although the symptoms can worsen with sexual intercourse, it does not usually cause pain with sex. 

Diagnosis

After a careful history that includes questions about general health, douching, and sexual activity, a clinician will perform a pelvic examination.  Specifically, a sample of the vaginal discharge is placed on a slide and is examined under the microscope in the clinician’s office.  For women who get BV on a recurrent basis, and are not at risk of a sexually transmitted infection, they may be treated by their primary clinician without a pelvic exam if their symptoms are classic and the same as their previous confirmed case.

Treatment options

Once the symptoms of bacterial vaginosis develop and become bothersome, the condition is treated with antibiotics.

1)    Metronidazole
This can be taken by a woman orally (as a pill) or applied topically to the vagina with an applicator.  Recommended regimens are:
•    Metronidazole 500mg by mouth twice daily for seven days
•    Metronidazole gel 0.75%- 5grams in vagina at bedtime for five days

Both regimens are equally effective.  Side effects of oral metronidazole include bad (metallic) taste and nausea.  While taking metronidazole, the women must not consume alcoholic beverages or they will experience a serious interaction, and develop symptoms of severe nausea, skin flushing, palpitations, and dizziness.  This may occur with even one drink, or by using a cough syrup with alcohol.  It is best to avoid drinking for 72 hours after the last dose of metronidazole to be sure it is completely out of the system.

The vaginal gel formulation of metronidazole is less likely to cause these gastrointestinal symptoms compared to the oral form, but alcohol should still be avoided.  The main disadvantage of the vaginal gel is that many women find it is messy. 

2)    Clindamycin
•    Clindamycin vaginal cream 2 percent used nightly for seven days
•    Clindamycin 300gm tablets taken twice daily for seven days
•    Clindamycin Ovules, 100mg intravaginally once daily for three days
•    One day clindamycin application (Clindesse®)

A side effect of Clindamycin cream is that it can weaken latex condoms

The choice between metronidazole and clindamycin, and whether the medication is taken as a pill or used as a cream is based on patient preference, insurance coverage, and previous efficacy.   Be sure to tell the treating clinician your preferences.

As stated before, there is no need to treat the male sexual partner of woman with BV, even in recurrent cases.

Recurrent Infections

This is frustratingly common.  More than fifty percent of women with initial improvement after therapy have a recurrence of BV in twelve months.  The best treatment of recurrent infection is unclear.  A prolonged course of metronidazole or clindamycin may be used and in some cases, a long-term twice-weekly “maintenance” use of metronidazole vaginal gel may be helpful.  Using a different form of therapy may be tried (switching from topical therapy to pills).

Follow-up

There is no need to test a woman whose symptoms of BV have resolved for persistent infection.  If the symptoms clear with therapy, treatment is presumed to have worked.

II. Vaginal Candidiasis

This form of vaginitis is also called “vaginal yeast infection.”  It is a very common problem in pre-menopausal women.  As many as 75% of women will develop this condition at least once in their lives.  It is not considered to be a sexually transmitted infection, but if a woman’s male partner has a yeast infection of the penis (called balanitis), partner treatment should be considered to improve resolution.

Candida Albicans is the species of yeast that most commonly causes vaginal candidiasis.  It normally lives on the mucous membranes of the vagina in small amounts.  When there is a disruption in the normal ratio of lactobacillus and yeast in the vagina, candida can multiply and cause the typical symptoms.

Common Inciting factors include

1)    Use of antibiotics.  These reduce the amount of healthy bacteria in the vagina that normally keep the small amount of yeast in check.
2)    Hormonal Contraceptives. Use of contraceptives that increase estrogen in a woman’s body can alter the normal vaginal environment and favor the growth of yeast.
3)    Diabetes. Increased blood glucose and reduced ability to fight infections in diabetes play a role.
4)    Immunosuppression. A woman has less ability to fight infection if she has HIV, advanced kidney disease, or is on immunosuppressive medications because of organ transplantation.  Oral steroids can also cause this.
5)    Pregnancy (possibly).

Signs and Symptoms

Vulvar itching is the most common and predictive symptoms of vaginal candidiasis.  Other symptoms include swelling of the vulva and labia.  In many cases, there is a vaginal discharge that is white, lumpy, thick, and curd like – and may be compared to cottage cheese

Diagnosis

To accurately diagnose vaginal candidiasis, the clinician will take a complete history, including medications, and perform a physical exam that includes a pelvic exam.  During the pelvic exam a sample of the discharge will be examined under the microscope for the characteristic appearance of yeast forms.  A culture may be sent in recurrent cases, complicated cases, or when a patient does not respond to medication as expected.  (There has been a rise in the prevalence of yeast infections resistant to over-the-counter treatments and some prescription medications).

Treatment

After yeast is confirmed, prescription creams are often prescribed.  They will usually work in cases where the over-the-counter product was ineffective.

There is also an oral treatment with an antifungal medication called fluconazole that is effective and convenient.  It usually requires only one dose.  In severe cases, a second dose can be taken 72 hours later.  It is generally well tolerated, but may not be recommended if the patient is taking other medications that may cause an interaction, and it should not be used during pregnancy.

Recurrent Vaginal Candidiasis

Despite accurate diagnosis and effective therapy, about five percent of women will have a rapid recurrence of vaginal yeast infection.  The patient should be examined again carefully to ensure that she does not have another type of infection that was masked by the yeast infection, or an underlying medical problem (such as diabetes), which increase the risk of infection.  If the diagnosis of vaginal candidiasis is certain, the patient may need to use antifungal creams for a longer course, or undergo re-treatment with two doses of fluconazole separated by 72 hours.  For women with a long history of frequent recurrent vaginal candidiasis, they can be treated with weekly use of clotrimazole suppositories, or regular use of an oral antifungal.  Additional measures include tighter control of blood sugar if the patient is diabetic, and the avoidance of synthetic underwear.

III. Trichomonas Vaginal Infection

Trichomonas is a sexually transmitted infection caused by a protozoon.  Risk factors for acquiring this infection include new or multiple partners, and sexual intercourse without consistent use of condoms.

Risks of untreated infection

1)    Increases the risk of acquiring HIV
2)    May increase the damage inflicted by other sexually transmitted infections
3)    May cause problems during pregnancy.  (See below for treatment recommendations during pregnancy.)

Signs and Symptoms

Women with trichomonas will often note a strong smelling vaginal discharge.  It may have a fishy odor similar to bacterial vaginosis.  With trichomonas, however, there are often more symptoms of vaginal irritation and sometimes pain.

Diagnosis

To diagnose trichomonas, a clinician will need to do a pelvic exam after a complete history and general physical exam.  The most common method to detect trichomonas is to take a fresh sample of the vaginal discharge and place it on a slide, dilute it with a drop of saline, and examine it under a microscope.  The clinician can see trichomonas immediately with a microscope.   It can also be found by culturing the vaginal discharge if trichomonas is strongly suspected, but the initial evaluation does not find the organism.

Treatment Options

An effective treatment for trichomonas in women who are not pregnant is two grams of metronidazole taken in one oral dose.  As stated before, when using metronidazole, the patient must abstain from alcohol (and for 72 hours afterwards) to avoid a syndrome of intense nausea and flushing. 

Recently, a second medication, tinidazole was approved for treatment of trichomonas.  It is also taken as a single two-gram dose.  Tinidazole is as effective as metronidazole, and some studies suggest it might be better tolerated.

During pregnancy, it is unclear whether women without symptoms should be treated, as the medication may increase the risk of some pregnancy problems.  If a pregnant woman has bothersome symptoms, treatment with metronidazole may be initiated.  Another approach is to control symptoms during pregnancy with clotrimazole vaginal cream, and then use metronidazole for cure after delivery.  Some clinicians prefer to avoid using metronidazole if a woman is breast-feeding, as it is unclear whether it is safe for a growing infant to be exposed to this drug.

As trichomonas is sexually transmitted, the partner of a woman with trichomonas should be given antibiotics as well.

Recurrent Infection

This usually results from not taking the medication properly, or reinfection from having sexual intercourse with an untreated partner.  But in cases where the trichomonas is resistant to the initial treatment, retreatment or use of other medications will lead to cure.

IV. Chlamydia Infection

Chlamydia vaginal infection is a sexually transmitted infection caused by bacteria.  It is the most common sexually transmitted infection in the United States.  It cannot be acquired by sharing towels, toilet seats, or casual contact.  It is passed to a woman from a man with chlamydial infection during sexual intercourse

Risk Factors

Because this is a sexually transmitted infection, the risk is highest from sexual intercourse with a new partner with an untreated infection.  Nevertheless, even in seemingly stable long-term relationships, a man who has sexual relations outside of the relationship can infect his partner. 

Chlamydia disproportionately affects young women.

Risks of Untreated Infection

If treated early, chlamydia is easily cured and should not cause permanent harm.  An untreated chlamydia infection, however, can spread to other organs of the reproductive system, and can even ascend into the abdomen causing a serious, possibly life-threatening infection.  If not detected, it can cause severe problems during pregnancy.

Signs and Symptoms

These can be quite variable.  Some women have a lot of pain, discharge and fever.  Others may notice only a minor vaginal discharge.  Still others have no symptoms as all.  It is important for women to be alert to unusual vaginal discharge if they are in a new sexual relationship, especially if condoms were not used. Other symptoms to be alert to include mild bleeding or “spotting” in between menstrual periods, pain with sexual intercourse, and even burning with urination that seems like a urinary tract infection.

Diagnosis

After taking a complete history including sexual activity, the clinician will do a pelvic exam.  Inspection of the cervix for discharge can provide clues to this infection.  Also, a cervix that is painful when examined by the speculum (an instrument used to help inspect the area) or by pressure from the examiner’s fingers can reveal a chlamydia infection.  It can also be detected in a urine sample, or from swabs of the vagina taken by the woman herself and submitted to a lab.

Treatment Options

For women at high risk of chlamydia, or after a physical exam that strongly suggests chlamydia, a clinician should treat the patient for chlamydia without waiting for the culture results.  Chlamydia is best treated early, and the benefits outweigh the risks of treatment with antibiotics.  In cases where the patient is asymptomatic, is deemed low risk for a sexually transmitted infection, and the physical exam is benign, it is reasonable to wait 48 to 72 hours for the cultures to return before initiating treatment.

In cases where the vaginitis caused by chlamydia is mild (or when the patient is asymptomatic), the following regimens are effective:

•    Azithromycin 1gram taken by mouth (all at once)
•    Doxycycline 100mg tablets.  One pill twice a day for seven days (not to be used in pregnancy

For pregnant women, either Azithromycin (as above) or Amoxicillin 500mg tablets, one pill twice a day for seven days is recommended.

As chlamydia is a sexually transmitted infection, the partner of a patient with chlamydia should also be treated with antibiotics.  A patient should abstain from sexual activity for   at least 96 hours after completion of treatment to ensure that the infection is entirely cleared.

Follow-up

If a patient takes the medications prescribed, and the symptoms disappear, a routine follow-up culture (“test for cure”) is not recommended.  However, if there is any doubt about medication use, or if the symptoms persist, the woman should be retested.  It may be necessary to wait a few weeks before retesting, as retesting too soon may lead to a false positive for persistent infection.

Any women with a new diagnosis of chlamydia should be thoroughly screened for other sexually transmitted infections that might be associated with chlamydia such as gonorrhea.  HIV status should be determined, and for women with certain risks, it is also reasonable to check for syphilis, which is often asymptomatic.

Prevention

Beside abstinence or monogamy, the most effective way for a woman to prevent this infection is to insist her partner(s) consistently use a latex condom during sexual intercourse.

V. Gonorrhea

A vaginal infection caused by gonorrhea is a sexually transmitted bacterial infection
Like other sexually transmitted infections, it cannot be acquired by sharing towels, toilet seats or casual contact.  It is passed to a woman from a man infected with gonorrhea during sexual intercourse. (An infected woman will also transmit gonorrhea to a man during sexual intercourse just as easily).

Risk Factors

Because this is a sexually transmitted infection, the risk is highest from sexual intercourse with a new partner.  It can also be introduced into a stable relationship if the man is not monogamous.  Beside abstinence or monogamy, the most effective way for a woman to prevent this infection is to insist her partner(s) consistently use a latex condom during sexual intercourse..

Risks of Untreated Infection

Gonorrhea is often more aggressive than chlamydia, and it is well known that an untreated infection can rapidly spread and do serious harm.  It can scar a woman’s reproductive system and permanently affect fertility; it can also complicate pregnancy.  Fortunately, this infection can also be easily cured and should not cause permanent harm if caught early. 

Signs and Symptoms

The symptoms can be mild, moderate or severe.   It can cause severe pelvic or abdominal pain, vaginal discharge, and fever.  But a significant percent of women have only a minor vaginal discharge or itching of the labia.  And, in some cases, this infection can cause no symptoms at all.

It is important for women to be alert to unusual vaginal discharge if they are in a new sexual relationship, especially if condoms were not used. They should also be alert to symptoms of mild bleeding (“spotting”) in between menstrual periods or pain with sexual intercourse.

Diagnosis

If gonorrhea is suspected, the clinician will start with a complete history including sexual activity, then do a careful pelvic exam.  Often, in gonorrhea the cervix will be very painful when examined with pressure from the examiner’s fingers.  Similar to chlamydia, the definitive diagnosis of gonorrhea is made with a culture taken from the cervix during pelvic exam.  It can also be detected in by a urine sample if a lab has the right testing equipment.

Treatment Options

As gonorrhea can be a very aggressive infection with immediate risk to a woman’s health, a clinician should not hesitate to start antibiotic therapy if gonorrhea is suspected.  This infection also responds best when treated early, and the benefits outweigh the risks of treatment with antibiotics while awaiting the culture results.

In cases where the vaginitis caused by gonorrhea is mild (or when the patient is asymptomatic), the following treatment is recommended by the Centers for Disease Control and Prevention (CDC):
Ceftriaxone 125 mg IM in a single dose
    OR
Cefixime†400 mg orally in a single dose or 400  mg by suspension (200 mg/5ml)
   
Alternative Regimens
Spectinomycin† 2 g in a single intramuscular (IM) dose
    OR
Single-dose cephalosporin regimens
 † Spectinomycin is currently not available in the United States.
(Other single-dose cephalosporin therapies that are considered alternative  treatment regimens for uncomplicated urogenital and anorectal gonococcal  infections include ceftizoxime 500 mg IM; or cefoxitin 2 g IM, administered  with probenecid 1 g orally; or cefotaxime 500 mg IM. Some evidence indicates  that cefpodoxime 400 mg and cefuroxime axetil 1 g might be oral alternatives. Note: oral treatment with fluoroquinolone antibiotics are no longer recommended because of resistance)

In more serious situations where the patient is having significant pelvic or abdominal pain, the following is recommended:
An intramuscular injection of ceftriaxone with oral doxycycline.  (Metronidazole should also be added if the patient recently had pelvic surgery, is suspected of having an abscess, or has BV or trichomonas concurrently).

Gonorrhea is a sexually transmitted infection, so the partner of a patient with gonorrhea should also be treated with antibiotics.  A patient should abstain from sexual activity for hours after treatment to ensure that the infection is entirely cleared

A new diagnosis of gonorrhea should prompt a screen for other sexually transmitted infections such as chlamydia and HIV.  Syphilis testing should also be considered.

Follow-up

If a patient takes the medications prescribed, and the symptoms disappear, a routine follow-up culture (“test for cure”) is not recommended. If the symptoms persist, however, the woman should be retested.

Prevention

As discussed earlier, women who are sexually active should use condoms consistently in non-monogamous relationships.  A clinician may want to routinely test women for asymptomatic gonorrhea based on the prevalence of the disease in their area during annual or semi-annual pap smears.

VI. Other Causes of Vaginitis

Atrophic vaginitis

This is caused by decreased levels of estrogen leading to thinning of the lining of the vagina.  Although vaginal secretions diminish and may lead to dryness, irritation can cause the sensation of increased discharge.
This condition commonly occurs in women after menopause, but can also occur if women take medications that lower estrogen, after childbirth, and with breast-feeding.  It will usually respond quickly to the use of estrogen cream.

Allergic or Irritant Vaginitis

A woman may be sensitive to variety of common products such as soaps, scented toilet paper, panty liners, perfumes, and latex condoms.  These can cause irritation, swelling and some discharge.  If a thorough evaluation for other types of vaginitis does not reveal a cause, irritant vaginitis should be suspected.  It is sometimes very difficult, however, to determine which product is causing the problem.  If identified, avoidance will be curative.

Physiological Leukorrhea

Sometimes the estrogen level in a woman’s body changes the normal amount of vaginal discharge unexpectedly.  This may be caused by increased sensitivity of a woman’s vagina to estrogen. The normal discharge can become thicker.  There is no harm caused by this, and no treatment is needed.  Physiological leukorrhea can only be diagnosed after a very careful elimination of the other forms of vaginitis.

More information on the Internet

National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Allergy and Infectious Diseases
(www3.niaid.nih.gov/healthscience/healthtopics/vaginitis/index.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)