Vaginitis is the medical term for infection or inflammation of the vagina. It is a problem that is commonly encountered in the general gynaecologist’s clinic. In some cases, the vulva and cervix may be affected by infection and inflammation as well, giving rise to vulvitis and cervicitis respectively.
Common symptoms of vaginitis include vaginal discharge, itch and discomfort.
Some women may also experience dysuria (pain felt on urination), superficial dysparenunia (pain felt on penetration during sex) and spotting (typically after sex or outside of normal periods).
The most common causes of vaginitis are bacterial vaginosis, candida (yeast) infection and trichomonas infection. They account for 90 percent of cases. Less common but significant causes of vaginitis are infections caused by sexually-transmitted organisms such as chlamydia, gonorrhoea and herpes.
Not all cases of vaginal discharge are due to infection. Vaginal discharge can be normal (‘physiological discharge’). It can also be caused by presence of foreign objects in the vagina, allergic reactions, cervical conditions and rarely genital tract cancer. In postmenopausal women, vaginal discharge is commonly due to atrophic changes (‘atrophic vaginitis’).
* Cervical ectropion is a condition in which the inner cervical cells are found on the outer part of the cervix.
The normal vaginal environment is a delicate ecosystem of ‘healthy’ bacteria and small amounts of candida (yeast). The normal pH of the vagina is usually acidic in nature. Lactobacillus is the main regulator of vaginal pH by making lactic acid. Maintaining the vaginal pH at an acidic level inhibits overgrowth of ‘healthy’ bacteria and yeast and prevents infections from bad bacteria and viruses.
Discharge flows from the vagina daily as the body’s way of maintaining a normal healthy environment. Normal physiological vaginal discharge consists of cervical and vaginal cells, bacteria, water, electrolytes and other chemicals. Normal discharge is usually clear or white, thick and mucouslike. There may be a slight odour. Vaginal discharge may become more noticeable near ovulation and in the week before the menstrual period.
The vaginal pH can change under the influence of various factors:
Disturbance of the normal vaginal pH can alter the composition and balance of the vaginal ecosystem. This leads to overgrowth of ‘healthy’ organisms and infections from bad organisms, resulting in vaginitis.
Although vaginal discharge can be physiological, it is advisable to seek medical advice under any of the following circumstances:
Bacterial vaginosis occurs when lactobacillus in the vagina is replaced by other bacteria. It is the most common cause of vaginitis, accounting for 40-45 percent of cases and usually causes a ‘fishy’ thin off-white vaginal discharge, which is more noticeable after unprotected sex.
Although the majority of affected women are sexually active, bacterial vaginosis can occur in women who have never had sex. Other predisposing factors for bacterial vaginosis include oral sex, intrauterine contraceptive devices, vaginal douching and pregnancy.
50 percent of bacterial vaginosis cases do not cause any symptoms and do not need treatment, unless the woman is undergoing gynaecological surgery or is pregnant and has previous preterm birth. Testing and treatment of male sexual partners is not needed and unhelpful in preventing repeat infection.
Treatment of bacterial vaginosis consists of a course of antibiotics and avoiding vaginal irritants. Recommended antibiotics are metronidazole (flagyl) or clindamycin given through either the oral or vaginal route. Avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter. Metronidazole pills also interact with warfarin.
50 percent of affected women have a repeat episode of bacterial vaginosis within one year. In women who have frequent episodes of bacterial vaginosis, these treatment strategies may be helpful:
Candidiasis occurs when there is an overgrowth of the yeast organism called candida, which is usually found in small numbers in the normal vaginal environment. It is the second most common cause of vaginitis, accounting for 20-25% of cases.
It usually causes a thick white odourless discharge. Vaginal itch and soreness are also prominent symptoms. Predisposing factors for candidiasis include pregnancy, diabetes and medical conditions which cause low immunity, antibiotics and birth control pills.
20 percent of candidiasis cases do not cause any symptoms and do not need treatment. Testing and treatment of sexual partners is not needed because candidiasis is not considered sexually transmitted.
Treatment of candidiasis consists of a course of antifungal medications given by the oral or vaginal route. Vaginal antifungal medications may weaken latex condoms so additional contraception is needed when the woman is using antifungals. 5 percent of women have recurrent candidiasis (four or more repeat episodes of candidiasis in one year) and may benefit from the following strategies:
Trichomonas is a sexuallytransmitted parasite with a high transmission rate of at least 70 percent after just one exposure to an infected partner. It is the third most common cause of vaginitis, accounting for 15-20 percent of cases.
50-75 percent of infected persons have no symptoms. Common symptoms include foul-smelling yellow-green vaginal discharge and vaginal itch.
It is important to treat all cases of trichomonas infection, even if there are no symptoms. Trichomonas infection can spread from the vagina to the upper genital tract (i.e. the womb, tubes, ovaries), causing damage which can affect fertility and increase the risk of ectopic pregnancy. Untreated trichomonas infection in pregnancy is associated with a high risk (30 percent) of preterm birth. Testing and treatment of sexual partners is mandatory. Treatment consists of a course of oral antibiotics (metronidazole or tinidazole).
Atrophic vaginitis refers to a type of vaginitis that occurs because of oestrogen deficiency, usually after menopause. It occurs in up to 40 percent of postmenopausal women.
Oestrogen stimulates the growth of lactobacilli in the vagina. Lack of oestrogen causes thinning of the vaginal skin and increases the pH of the vaginal environment. This predisposes the genital area to infection.
Because the problem is mainly due to lack of oestrogen, treatment of atrophic vaginitis usually depends on replacing oestrogen in the tissues. Usually a cream, pessary or vaginal tablet or ring containing oestrogen is prescribed to replace oestrogen levels in the genital area. If there are other menopausal symptoms that require treatment, oestrogen is delivered in a more generalised form via an oral tablet or skin patch.
Vaginal moisturisers and lubricants may also be given but these are usually not as effective as oestrogen. Antibiotics are not needed in the treatment of atrophic vaginitis.
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