Vaginitis

Natural fluctuations in the balance of the normal bacteria and yeast that live in the vagina (also known as the vaginal microbiome) occur during the menstrual cycle and throughout a woman’s life.  During a woman’s reproductive years, the vaginal microbiome is mostly influenced by several factors:  the effects of estrogen on the vagina’s cells, the predominance of the lactobacillus species of bacteria in the vagina, and the level of the vagina’s pH.  All of these factors can be influenced and disrupted by the use of antibiotics, sexual activity, and the menstrual period.

Signs and symptoms of vaginitis may include an unusual vaginal discharge, vaginal malodor, itching, a sense of irritation, painful urination, painful intercourse, and even vaginal bleeding.

Vaginal discharge is the most common complaint of women with vaginitis. When evaluating a woman with a vaginal discharge, it is important not only to establish the consistency and color of the discharge, but to take into account the woman’s age and sexual history. For a sexually active premenopausal woman, the gynecologist must consider sexually transmitted infections and yeast infections.  In a sexually active postmenopausal woman, a post-intercourse bloody vaginal discharge may be the result of vaginal atrophy.

Vulvovaginal candidiasis

Vulvovaginal candidiasis is commonly called a “vaginal yeast infection.”  It is usually caused by a yeast (which is a type of fungus) called Candida. Candida normally lives inside the body (in places such as the vagina, mouth, throat, and gut) and on the skin without causing any problems. But, sometimes candida can over-multiply if the environment changes in a way that encourages its growth: then it transforms into an infection.  Vaginal candidiasis is frequently seen in the setting of increased sexual activity, likely due to the yeast organisms gaining entry into the vaginal epithelium (lining) via micro abrasions from sexual intercourse.

The vaginal discharge associated with vulvovaginal candidiasis is non-odorous, thick, white-yellow, curd-like, and it sticks to the inner sides of the vulvar labia, causing itching (sometimes intense) and burning.  On vaginal examination, the discharge is typically found on the sidewalls of the vagina.  The vulva can appear erythematous (red), swollen, and in severe cases, have fissures (small, painful cuts) and abrasions of the vulvar skin.  Risk factors contributing to vulvovaginal candidiasis include stress, recent antibiotic use, poorly controlled diabetes, pregnancy, steroid use, HIV and other conditions of immunosuppression.

If clinically there is any question whether a white vaginal discharge is candidiasis, examining a sample under a microscope is helpful.  Yeast organisms and white blood cells can be seen microscopically.

Acute vulvovaginal candidiasis is treated with antifungal medications, either orally or vaginally using a cream, tablet, or suppository.  It is important that the risk factors for vulvovaginal candidiasis be addressed and managed to avoid recurrent infections.  Combining standard therapy with complementary therapies (for example, Greek yogurt) can also be considered to provide relief although the effectiveness varies.

Bacterial vaginosis

Bacterial vaginosis (BV) has been reported to be the most common disorder of the female lower genital tract in reproductive-age women.  An estimated 7.4 million cases occur each year in the U.S.  The prevalence rates are in the range of 15% among pregnant women, 20-25% among young women seen at student health clinics, and up to 30-40% among women seen at sexually transmitted infection clinics.  It occurs when an imbalance develops in the normal microbiome of the vagina; more specifically, when the normally dominant vaginal bacterium Lactobacillus is replaced by a mix of other bacteria.

The vaginal discharge associated with BV is homogeneous, thin, milky-gray, malodorous and it causes vulvovaginal discomfort and vulvar irritation.  The malodor is characteristically fishy.  Typically, it is this self-perceived fishy vaginal odor that makes women seek treatment.

Risk factors for bacterial vaginosis include unprotected vaginal sexual activity with multiple partners, use of a intrauterine device (IUD), shared sex toys, smoking, frequent use of scented soap or bubble bath, douching, or use of any over-the-counter vaginal hygiene products.

The diagnosis is made based on the combined finding of the typical vaginal discharge of BV and the absence of vulvovaginal inflammation (redness), along with:  the microscopic finding of vaginal cells studded with bacteria (‘clue cells’), decreased acidity in the vagina (pH >4.7), and a positive ‘whiff test’ (when by adding a drop of a potassium solution to a sample of the discharge on a glass slide, the fishy odor of the discharge becomes obvious).

Treatment for bacterial vaginosis consists of various regimens of oral or vaginally-applied antibiotics (metronidazole or clindamycin).  In one study in 2009, combining oral supplements of lactobacillus with metronidazole was more effective than metronidazole alone in resolving BV. Women with BV should be advised to stop douching or using bubble bath, and to wash with hypoallergenic bar soaps.

Trichomoniasis

Trichomoniasis (or “trich”) is a sexually-transmitted infection caused by a single-cell parasite called Trichomonas vaginalis.  It is acquired by the transmission of bodily fluids during heterosexual intercourse or among women who have sex with women utilizing shared sex toys.

Signs and symptoms of trichomoniasis usually develop within a month of exposure, however up to half of women will not develop any signs or symptoms, though they can still pass on the infection to others. Trichomoniasis causes a yellow-green, fishy, malodorous vaginal discharge that can be thick, thin, or frothy. The discharge causes soreness, swelling, and itching in the vagina and vulva, and sometimes the inner thighs can also be itchy.  Additionally, there may be pain during urination or sexual intercourse and possibly even be vaginal bleeding after intercourse. On speculum examination by the gynecologist, the cervix may have a strawberry appearance.  Men are usually asymptomatic, but they can develop a thin, white penile discharge, pain with urination or ejaculation, urinary frequency, and soreness, swelling, and redness around the head of the penis.

Risk factors for trichomoniasis include having a history of other sexually transmitted infections, a previous episode of trichomoniasis, multiple sex partners, and unprotected sex. Serious complications of trichomoniasis can develop in pregnant women. Pregnant women with trichomoniasis may deliver prematurely, have a baby with a low birth weight, and transmit the infection to the baby as it passes through the birth canal. Having trichomoniasis also appears to make it easier for women to become infected with HIV, the virus that causes AIDS, and to develop pelvic inflammatory disease (PID).

The diagnosis of trichomoniasis is made by either finding the parasite under the microscope or by sending vaginal swabs or urine samples to the laboratory for identification of trichomonal genetic material. It is common practice for the gynecologist to simultaneously test for other sexually transmitted infections, like gonorrhea or chlamydia, because many women with trichomoniasis also have these.

Treatment is with the oral antibiotic metronidazole, which cures 95% of women with trichomoniasis if the sex partner is treated at the same time. Of note, drinking alcohol should be avoided for at least 72 hours after taking metronidazole, otherwise there could be nausea, vomiting, cramps, flushing, and headaches.

People can get reinfected with trichomonas even after being treated: about 20% of women get infected again within 3 months of initial treatment.  To avoid re-infection, the sex partner needs to be treated and sex should be avoided until symptoms completely resolve (in about a week).

Atrophic Vaginitis

Atrophic vaginitis is the drying, thinning, and inflammation of the vaginal walls that may occur when a woman’s estrogen levels decrease. As a result, the vagina is less elastic and more fragile.  Vaginal atrophy occurs most often after menopause (in more than half of menopausal women) when estrogen levels are permanently low.  But a drop in estrogen levels can also occur during the years leading up to menopause (known as perimenopause or menopausal transition), after surgical removal of both ovaries, while taking medications that can affect estrogen levels (such as some birth control pills), after pelvic radiation or chemotherapy for cancer, and as a side effect of breast cancer endocrine treatment (such as with tamoxifen and aromatase inhibitors, like anastrozole).

For many women, atrophic vaginitis causes a recurring distressing vaginal discharge that is thin, watery, yellow or gray in color. It also causes itching, discomfort or pain during intercourse, light bleeding after intercourse, decreased lubrication during sexual activity (usually the first sign of atrophic vaginitis), and when severe, shortening and tightening of the vaginal canal. Atrophic vaginitis is also associated with urinary symptoms such as burning and/or urgency with urination, more frequent urinary tract infections, and urinary incontinence.

Simple effective local treatments for the symptoms of atrophic vaginitis are available such as lubricants and moisturizers, however, neither moisturizers nor lubricants will completely restore the health of the vagina. For women who fail to gain relief from moisturizers and lubricants and who may by now have moderate to severe symptoms, applying prescription topical estrogen (in the form of a cream, vaginal pill/suppository, or a ring) to the inside of the vagina helps thicken the vaginal tissues and restore the normal acid balance of the vagina. This increases vaginal moisture and sensitivity. Finally, for women in whom hormonal therapy is not an option or is ineffective, fractionated CO2 laser therapy using the MonaLisa Touch laser system in the office has been shown to significantly improve the symptoms of vaginal atrophy by stimulating the vagina’s connective tissue to produce new collagen. This promotes improved blood flow and tissue regeneration for vaginal lubrication and elasticity.

Regular sexual activity, either with or without a partner, can help prevent atrophic vaginitis. Sexual activity increases blood flow to the vagina, which helps keep vaginal tissues healthy. Refraining from smoking is also preventive.  Ways to keep atrophic vaginitis from worsening include avoiding perfumes, powders, deodorants in the vaginal area and tight-fitting clothing and panty liners.

Desquamative Inflammatory Vaginitis

Approximately 8% of patients with chronic vaginitis have desquamative inflammatory vaginitis (DIV). This condition is often missed or misdiagnosed as trichomoniasis, as it has similar symptoms, including yellow-greenish discharge, itching and burning, redness, and painful intercourse.

On physical examination, there is a discharge that is essentially pus—which can be copious, redness of the vagina and vulva, and some contact bleeding can occur with placement of the speculum in the vagina.  Under the microscope, a sample of the vaginal discharge will typically reveal many white blood cells.

DIV is a diagnosis of exclusion where infections should be ruled out. Most patients will have first been treated for infectious causes multiple times with no or partial resolution of symptoms.

Irritant Vaginitis

Irritant vaginitis is a vaginal irritation without inflammation and is most often caused by an allergic reaction or irritation.  Chemicals in vaginal sprays, douches, perfumed soaps, detergents, fabric softeners or spermicidal products can cause irritant vaginitis. Even chemicals in clothing can cause symptoms.   Alleviation of symptoms is achieved by avoiding the irritant.

Viral Vaginitis

Viruses are a common cause of vaginitis, with most being spread through sexual contact. One type of virus that causes viral vaginitis is the herpes simplex virus (HSV, or simply ‘herpes’).

The main symptom is pain in the genital area associated with lesions and sores. Theses sores are generally visible on the vulva, but may be found inside the vagina during a speculum exam. Often stress or emotional situations can be a factor in triggering an outbreak of vaginal herpes.

Herpes viral vaginitis is treated with oral anti-viral medications which can decrease the pain and shorten the length of the outbreak.