Vaginal Discharge: What You Need to Know**
**Vaginitis**: This is a common diagnosis in women's healthcare, and it often leads to symptoms like increased vaginal discharge, itching, burning, pain while urinating, and sometimes an unusual odor. It's important to note that some vaginal discharge changes naturally with a woman's menstrual cycle. If a doctor suspects an infection, they may test for Chlamydia and Neisseria gonorrhoeae, two common culprits. In postmenopausal women, discomfort, dryness, and even light bleeding can be caused by atrophic vaginitis, which is linked to hormonal changes. Certain medications like isotretinoin and some contraceptives can also lead to dryness and itching. Overdoing personal hygiene with soap and using highly absorbent panty liners can irritate the area. If someone has tried self-treatment with antifungal agents and their symptoms persist, it's crucial to seek a clinical examination.
**Diagnosis**: Doctors typically use office microscopy to diagnose vaginitis. If a large number of white blood cells are present, it's unusual and might suggest trichomoniasis, a sexually transmitted infection. If trichomonads aren't found, the doctor may consider testing for gonorrhea or chlamydial infection. There's also an over-the-counter diagnostic kit called Fem V, which can help. A positive result suggests bacterial vaginosis or trichomoniasis, while a negative result is likely a yeast infection.
**Bacterial Vaginosis: More Than Just Discharge**
**Bacterial Vaginosis (BV)**: BV occurs when there's a change in the usual balance of bacteria in the vagina, with an overgrowth of certain types. It's the most common cause of vaginal discharge and often comes with a foul odor. Surprisingly, more than half of women with BV don't experience any symptoms. However, BV is associated with some serious issues like postoperative infections, pelvic inflammatory disease, premature delivery (in specific cases), and an increased risk of HIV transmission.
**Risk Factors**: Certain behaviors or conditions can increase your risk of getting BV, including smoking, using intrauterine contraception, having a new male sexual partner, engaging in sex with another woman, or using products like perfumed soaps or douches.
**Diagnosis and Treatment**: BV can usually be diagnosed through a combination of medical history and laboratory tests. While patients might notice a distinctive "musty cheese" odor, the absence of an obvious smell doesn't rule out BV. Laboratory tests, such as Gram staining or the Amsel criteria, help doctors confirm the diagnosis.
**Treatment Options**: Fortunately, BV is treatable. Medications like clindamycin and metronidazole are commonly used, and they are effective. Metronidazole can be taken orally, while clindamycin is available as a vaginal cream. There are also lactobacilli gelatin tablets for the vagina that work well. Although less common, tinidazole is another option. Some treatments are FDA-approved, but it's essential to follow your doctor's advice on what's best for you. Avoid hydrogen peroxide douching and triple-sulfonamide cream, as they aren't effective.
**Recurrent BV**: If BV keeps coming back, it can be a challenge. Doctors will want to confirm the diagnosis, identify risk factors, and explore other potential causes. Treatment might involve using metronidazole gel regularly, but this can increase the risk of vaginal candidiasis (yeast infection). If all else fails, your doctor may suggest a more extended period of treatment with metronidazole gel. Treating sexual partners isn't typically effective in preventing recurrence. Some individuals find relief from recurrent BV by using vaginal suppositories or consuming yogurt with Lactobacillus bacteria.
Candidal Vaginitis: It’s More Common Than You Think
Vulvovaginal Candidiasis (VVC): After bacterial vaginosis, VVC is the next most common cause of vaginal discomfort, affecting 70% to 75% of women at some point in their lives. Candida albicans is the primary culprit in 80% to 90% of cases. Risk factors for VVC include conditions like type 1 diabetes, recent antibiotic use, condom and diaphragm use, spermicides, oral contraceptive use, pregnancy, hormone replacement therapy, and immunosuppression. Interestingly, self-diagnosis by patients is often wrong, being unreliable 50% of the time. Even when a swab detects Candida, asymptomatic treatment is not advised. Since VVC isn’t sexually transmitted, it’s unnecessary for partners to undergo treatment. Recurrent VVC, defined as four or more symptomatic episodes in a year, can lead to complications like vulvar vestibulitis and chorioamnionitis, although these are rare.
Symptoms and Diagnosis: The most common complaint with VVC is a burning or itching sensation. A thick, curd-like discharge, inflammation, and lack of odor are usually indicative of VVC. However, in some cases, a thin discharge may be present despite the presence of VVC.
Diagnosis Methods: Office microscopy is often the first step in diagnosing VVC, but the gold standard is a culture. Vaginal pH is usually below 5.0 with C. albicans but can be higher with other non-albicans species. To rule out other conditions like trichomoniasis or bacterial vaginosis, a wet mount is performed. A potassium hydroxide (KOH) examination is also carried out but has varying sensitivity. Therefore, if a patient with persistent or recurrent symptoms has negative wet mount and KOH results, a culture is recommended. Rapid antigen testing is a more sensitive alternative to a wet mount, but a negative result still necessitates a culture.
Effective Treatment: Imidazoles are the primary treatment for VVC. Over-the-counter (OTC) intravaginal imidazoles like clotrimazole, miconazole, and tioconazole come in 1-, 3-, and 7-day regimens and are as effective as oral therapies. Single-dose therapy can be just as effective as multiple doses. However, lactobacillus, whether administered vaginally or orally, doesn’t prevent post-antibiotic-associated vaginal candidiasis.
Recurrent VVC: Around 5% to 8% of women experience recurrent VVC. Treatment typically involves a longer course of medication, followed by suppressive therapy using a weekly fluconazole dose for six months. It’s uncertain whether oral or intravaginal regimens are superior. Unfortunately, other remedies like boric acid, tea tree oil, garlic, douching, or treating male sexual partners haven’t proven effective in preventing recurrence. Lactobacillus in the form of suppositories or oral yogurt also doesn’t appear to help.
Trichomoniasis: The Sneaky Protozoan
Trichomoniasis: This infection is caused by a motile protozoan and affects millions of women worldwide annually, often transmitted sexually. Risk factors for acquiring it include multiple sexual partners and possibly changes in vaginal acidity. Men are usually asymptomatic carriers, but 10% of nongonococcal urethritis cases in men are caused by Trichomonas.
Symptoms and Diagnosis: Up to 50% of women with trichomoniasis don’t show symptoms. When they do, symptoms may include a yellow-green, foul-smelling discharge, vaginal burning, and painful urination. Physical examination may reveal cervical lesions, though this is rare. More common signs are a malodorous purulent discharge, vaginal tenderness, vulvar redness, and swelling. Office microscopy is the primary diagnostic tool. However, culture is the gold standard, as microscopic examination may not detect motile trichomonads in all cases. There are FDA-approved point-of-care tests for trichomoniasis, but they can produce false-positive results.
Effective Treatment: Metronidazole or tinidazole in a single-dose therapy is effective. An alternative is metronidazole taken orally twice daily for a week. Metronidazole gel is less effective, with less than a 50% cure rate. Patients allergic to metronidazole may need desensitization. It’s crucial to avoid alcohol while using nitroimidazoles. Metronidazole is considered safe in the first trimester of pregnancy. Since many male sexual partners are asymptomatic carriers, simultaneous treatment is advisable.
When Treatment Fails: If initial treatment with a single 2-gram dose of metronidazole fails, a trial of metronidazole, 500 mg twice daily for 7 days, or a single 2-gram dose of tinidazole is recommended. If these fail as well, a trial of tinidazole or metronidazole, 2 grams orally once daily for 5 days, is advised. Referral to a specialist is necessary if treatment remains unsuccessful.
Other Forms of Vaginitis: Besides VVC and trichomoniasis, other forms of vaginitis exist.
• Aerobic Vaginitis: This is characterized by purulent vaginal discharge due to an abnormal aerobic flora. It causes a foul-smelling non-fishy discharge, and sometimes inflammation and ulcers. Clindamycin topical treatment is often effective.
• Irritant and Allergic Vaginitis: These conditions can arise from various sources, such as spermicidal products, douching solutions, diaphragms, latex condoms, and topical medications. The remedy is to stop using the irritant.
• Cytolytic Vaginitis: This occurs due to an overgrowth of lactobacilli and squamous epithelial cell exfoliation. While it can mimic VVC, treatment involves discontinuing intravaginal medications.
• Desquamative Inflammatory Vaginitis: This condition involves copious purulent discharge with epithelial cell exfoliation, often linked to lichen planus. Treatment options include corticosteroids or clindamycin suppositories.
Remember, if you're experiencing unusual symptoms or discomfort, it's always a good idea to consult with a healthcare professional for proper evaluation and guidance.