Vaginitis and Vulvovaginitis

The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.

Vaginitis is one of the most common conditions that bring women to see a doctor and can affect females of any age. Vaginitis rarely indicates serious illness but should be treated by a physician if certain signs and symptoms are present or if self-help treatment does not work.

Any condition that ends in "itis" means there is inflammation, irritation or redness and swelling of the affected part. Therefore "vaginitis" implies inflammation of the vagina. The vagina is a tubular structure that leads from the uterus or womb to the outside of the body. The area around the entrance to the vagina is called the vulva and may be involved with the same condition that affects the vagina, so-called vulvovaginitis. There may be a discharge, and there may or may not be an odor. For ease of discussion, we will use the term "vaginitis" with the understanding we are also including conditions that affect the vulva also (correctly termed vulvovaginitis).

Often vaginitis is caused by an infection but may also be a result of other factors such as irritation and allergy. There is a delicate balance between the two major microorganisms normally found in the vagina of women during their reproductive years. These microorganisms are Candida albicans (a type of yeast or fungus) and Lactobacillus sp.(a bacteria). If anything disrupts the balance, vaginitis can result. There are other infectious causes for vaginitis including bacterial vaginosis (a group of several bacteria that cause the infection), Trichomonas vaginalis, chlamydia infection, genital herpes and human papilloma virus. The signs and symptoms, diagnosis and therapy of these causes of vaginitis are best discussed with each type of infection.

Vaginitis may result from non-infectious causes such as a change in the body’s normal hormonal balance as seen with puberty, the menopause, pregnancy, breast-feeding or even recent childbirth.

Certain health conditions such as diabetes do not actually cause vaginitis but make the woman who has the condition much more likely to develop vaginitis.

Other non-infectious causes for vaginitis include:

Certain skin conditions can result in symptoms of vulvovaginitis. Most of these conditions are benign, but rarely a malignant (cancerous) change may be present. The most common of the skin conditions causing symptoms of vulvovaginitis is not cancerous and is called lichen sclerosis et atrophicus, a thinning of the skin of the vulva that results in itching and irritation.

Allergy or reaction to any one or more of a number of substances can lead to symptoms of vaginitis. Some of the more common substances leading to vaginitis are

• feminine hygiene products such as sprays and powders,
• detergents used to wash undergarments,
• bath soaps and oils,
• spermacidal foams, gels and creams in addition to certain lubricants
• corticosteroid creams (cortisone used to treat itch and irritation can actually cause the same symptoms being treated)
• condoms and diaphragms
• tampons, especially those that are scented
• sexual implements
• sexual intercourse may result in vaginitis either from irritation if you are not adequately lubricated or reaction to the male’s ejaculate (yes, that means you can be allergic to your partner)

Finally, some medications cause vaginitis, most commonly broad spectrum antibiotics used to treat sore throats, etc. can affect the natural balance within the vagina.

What can I do to prevent vaginitis?

Avoid harsh soaps for bathing and for washing undergarments. Along the same line, do not use scented or dyed toilet tissue.

Do not wear tight fitting clothes such as jeans and slacks, and make sure your undergarments are pure cotton (avoid a cotton crotch with nylon or other synthetic on the outside - this traps the moisture). If you wear panty hose, you can cut the crotch out to "allow your bottom to breathe." Additionally, when you are around the house, wearing a skirt or smock without any undergarments will help keep the vulvar area dry.

Avoid spreading microorganisms from the rectum to the vagina by wiping from the front to the back after a bowel movement

Resist the temptation to eat and drink things that are high in sugar content.

Ask your doctor if the antibiotic he is placing you on is likely to cause a yeast infection. If he says "yes," you might consider using an anti-yeast medication.

All feminine products that are scented (including sprays, douches, and tampons) should not be used. The vagina has natural secretions which act as cleansing agents. If you have a vaginal discharge , odor, or irritation, it is better to actually treat the cause rather than try to douche it away. Although it is not necessary, if you feel cleaner douching once after your menstrual period, this should not cause any problems.

Thoroughly clean diaphrams and spermacide applicators after each use.

Make sure you are well lubricated before penetration occurs with sex. If an external lubricant is needed, make sure the product is water soluble.

Use condoms during sex. Multiple sexual partners increase the likelihood of vaginitis and other sexually transmitted diseases.

What is the best treatment for vaginitis? Can I use over-the-counter medications?

There is no single treatment that works for all types of vaginitis. An accurate diagnosis of the cause of the vaginitis will result in the treatment options most likely to get rid of your symptoms.

Yeast Infections

The most common symptoms of a yeast infection are irritation, itching, and a discharge that is white and curdy (like cottage cheese) and has no odor. It is safe and appropriate to use over-the-counter medications if you do not have any of the following:

• fever
• pelvic or stomach pain
• lesions or sores on your bottom or in the vagina
• fishy odor
• symptoms of a bladder infection such as frequency or burning on urination
• abnormal menstrual bleeding
• more than 4 vaginal infections within the past year

If you could be pregnant, have any of the above symptoms or if this is your first vaginal infection, it is best that you have a correct diagnosis by your doctor before treatment is begun. When using medication, you are more likely to eliminate the infection if you use the medication for a full 7 days - do not stop the medication even though your symptoms are better. It does not matter whether you choose the cream or the suppository form. If your symptoms are not gone after using the medication, you should see your doctor.

Note: If you are seeing your doctor for vaginitis, do not douche or use any vaginal medication or tampons for at least 72 hours before your visit. Also, your doctor can best diagnose the cause of the vaginitis if you are not on your menstrual period.

Common questions about yeast infections:

"Is it better to use the 3-day medications or the 7-day?" The cure rate is better with the 7-day preparations than with those you only use for 3 days. You can use the 3-day medications, but you are risking incomplete treatment.

"What about taking medication by mouth so I don’t have the mess associated with vaginal medication." There are several medications that can be taken orally for vaginal yeast infections. Most recently a single tablet of fluconazole has been approved by the FDA. But there is a 33% failure rate. Also, overuse of this medication will result in yeasts that are resistant to treatment. In most instances oral medication is best reserved for special situations such as chronic recurrent infections.

"What can I do if the yeast infection keeps coming back?" The first step is to make sure that it is indeed a yeast infection and even what kind of yeast infection it is. Your doctor should examine a sample of the discharge with a microscope, looking at the discharge in both a saline (salt water) preparation and KOH (potassium hydroxide) solution. Ask him or her what was seen? A simple inexpensive treatment for recurring yeast infections is to use boric acid capsules which you can make yourself (boric acid powder is placed in a zero-sized gelatin capsule available at the drug store). Initially the capsules are placed in the vagina twice a day for 2 weeks; then once a day, 2 days a week for 6 months.

Sometimes it is necessary to culture the discharge (take a sample and grow the yeast in a special mixture) to tell what kind of yeast infection it is. The most common type of yeast infection is called Candida albicans. There are also non-Candida albicans types of yeast that require special treatment to get rid of the infection.

Lactobacillus Vaginitis

Lactobacillus or cytolytic vaginits is one of the most under-diagnosed types of vaginitis. There is frequently a white discharge that may be mistaken for a yeast infection. Itching, irritation and burning of the vagina and vulva are frequent complaints. It is most often present during the 2 weeks before the onset of the menstrual period.

Lactobacillus is one of the normal microorganisms found in the vagina, along with yeast. An imbalance in the vagina can result in overgrowth of this microorganism. The diagnosis is made by examination of the discharge under the microscope. Treatment is a baking soda douche which can be made with 2 ounces of baking soda in a quart of warm water. The douche is used every other night for a week and 1-2 times per week thereafter as needed. Placing 2-4 tablespoons of baking soda in 1-2 inches of bath water once or twice daily provides external relief of symptoms. You should also avoid external sources of lactobacilli such as yogurt, discontinue medication to treat yeast, and use non-deodorized pads during your menstrual period.

Trichomonas Vaginitis

Trichomonas vaginitis or "trich" is caused by an organism that is predominantly sexually transmitted. Irritation of the vulva and vagina are common with this infection as is a frothy, greenish-yellow discharge which has an unpleasant odor. This infection is usually diagnosed by seeing the trichomonads under the microscope, and it may also be sometimes diagnosed with PAP smear or culture.

Both the woman and her partner should be treated for this infection, usually with metronidazole, both taking 4 tablets (2 grams) at one time. Alcohol should be avoided within 24 hours of taking the medication, and the drug should not be taken during the first three months of pregnancy.

Bacterial Vaginosis

This is caused by several species of bacteria that used to be called Gardnarella vaginitis. The discharge is usually dull grey and has an unpleasant fishy odor. Itching and irritation is uncommon. This form of vaginits is diagnosed by seeing "clue cells" under the microscope - "clue cells" are vaginal cells that have clumps of bacteria in and around them. We used to believe this is a sexually transmitted infection, but there is no evidence treating your partner will help prevent the infection. The infection may also be seen in girls before puberty and who are not sexually active.

Bacterial vaginosis is best treated with an oral antibiotic called metronidazole, taking one 500mg tablet twice a day for one week. While taking the medication you should not drink alcohol, and you can expect a metallic taste in your mouth until you finish the medication. Bacterial vaginosis can cause pelvic infection (so-called PID or infection of the uterus, tubes and ovaries), premature delivery in addition to infection after child birth or after surgery. Creams are also available but are more costly.

Chlamydial Infection

Chlamydia is one of the most common sexually transmitted infections and frequently has no signs or symptoms. Sometimes there is a non-irritating discharge, and sometimes the woman will have pelvic pain or burning on urination. It is important to understand there are other causes of these symptoms. Chalmydia infection can result in serious damage to the female organs - with pelvic pain, infertility, premature birth and serious infection after delivery or surgery. As with any sexually transmitted disease, prevention is the best approach. There are several tests used to detect this infection. Your doctor takes a small sample of the discharge, similar to the way a PAP smear is done. The treatment involves taking an oral antibiotic (usually doxycycline) twice a day for 7-14 days.

Herpes, Human Papilloma Virus and Other Sexually Transmitted Diseases

These are discussed in the section on Sexually Transmitted Diseases.