Vaginitis is inflammation of the vagina. It can occur for a variety of reasons, the most common are infections and imbalances of bacteria. Common symptoms of vaginitis include changes in the quantity or quality of vaginal discharge, itching, burning, pain with intercourse, and odor. Occasionally the symptoms may be accompanied by pelvic pressure and discomfort, and by burning with urination.
Almost every woman will have vaginitis at least once in a lifetime, and most several times. It is very common.
The vagina normally has several trillion bacteria present. These bacteria are not infectious – they are “colonizers” in that it is normal for them to be there, and they are helpful, in that they maintain the proper pH balance in the vagina, and their presence means that it is difficult for more invasive and infectious bacteria to move in. Lactobacillus and sacchyromyces are common “helpful” bacteria.
Anything that reduces the number of helpful bacteria can upset the balance and allow more invasive strains to move in and establish. Antibiotics, allergens, changes in glucose and insulin metabolism, changes in hormones and change in sexual partners are common reasons why this happens. Sometimes the cause is not known at all.
It is normal for the vagina to produce some discharge on a constant basis. This discharge lubricates the vagina, and is always present, but typically increases with sexual activity. It varies throughout the cycle from a clear appearance (a similar appearance and consistency of raw egg white), to a somewhat thicker white dishcharge, depending on the phase of the menstrual cycle.
Common Types of Vaginitis
Yeast Vaginitis (Candida)
The typical symptoms of a “yeast infection” are profuse white clumpy discharge and a lot of itching. Burning discomfort and redness in the vulvar area (outside of the vagina) can also occur. Antifungal medications over the counter can be helpful, and are typically available in suppository and cream form. They are available as 1, 3 and 7 days typically.
A medication can be prescribed to treat vaginal yeast infections, and is called Diflucan. It is typically taken as a “one time” dose, although some people feel that two doses, 12 hours apart, work better for more severe infections. Side effects are unusual.
If candidiasis is severe or recurrent, then we usually recommend looking for underlying diabetes or HIV, both of which can increase the likehood, severity and recurrence of candidiasis.
Probiotics can be helpful in re-establishing vaginal flora. Look for one that contains both lactobacillus and sacchyromyces, ideally with 20 billion CFUs per tablet. These are typically taken orally for a few months after a vaginitis, to help re-establish the normal population of bacteria. It is a good idea to use probiotics anytime that antibiotics have been used recently. Some people take probiotics on a daily basis to maintain healthy mouth and gut flora as well.
Bacterial Vaginosis
This is not actually “vaginitis” which causes actual inflammation of the vaginal tissue. Since this condition is usually not accompanied by inflammation, it is called bacterial “vaginosis” rather than actual “vaginitis”. Normal there are billions of bacteria in the vagina and most of them should be a healthy variety of bacteria called “lactobacillus” predominating. This kind of bacteria produces hydrogen peroxides that keeps other, potentially more harmful, bacteria at bay. When the number of lactobacillus decline (as a result of antibiotics, douching, poor health, introduction of other bacterial species through sexual intercourse, etc) and/or the number of potentially harmful bacteria increases, the result is bacterial vaginosis.
It used to be thought that the harmful bacteria was Gardnerella. Now we know that in addition to Gardnerella, there is also Bacteroides, Mycoplasma and others that can potentially cause problems.
Some women with BV have no symptoms and the condition is diagnosed when the clinician recognizes an abnormal discharge or odor while doing the exam. Other women notice an increased thin grey discharge with a fishy odor, particularly after intercourse.
We usually treat BV when we recognize it. It is particularly important to treat pregnant women with BV, since it has been linked to preterm delivery. We also treat it in non-pregnant women to relieve symptoms, but also because having BV makes it easier for more harmful bacteria such as Chlamydia and Gonorrhea and others to invade and spread. Women with BV who have procedures done such as hysteroscopies, cystoscopies, vaginal surgery, or hysterectomies, have higher risks of post-op infection if BV is present.
Treatment typically consists of an antibiotic that preferentially destroys the harmful bacteria and replacement of the helpful bacteria (lactobacillus). The antibiotic used to reduce the numbers of harmful bacteria is most commonly Metronidazole (Flagyl) either as an oral medication for 1-7 days, or as a vaginal topical medication (Metrogel) placed in the vagina for 5 days. There are a few alternatives if people don’t tolerate Metronidazole well, but they are usually more expensive.
At Women’s Health Connection, we usually recommend probiotics as well, consisting of some of the strains of lactobacillus that produce hydrogen peroxide, and sacchyromyces. Usually this needs to be taken as a tablet, since the amount found in foods such as yogourts is minimal. Several of the new medications coming on to the market for BV have both an antibiotic and a probiotic combined.
Trichomonas
This is a rather unusual vaginal infection that we see a few times a year. It typically causes an inflamed reddened cervix and vagina, and a foul profuse discharge. It is caused by a sexually transmitted parasite. The parasite typically does not cause problems for men, but can cause problem for women. The parasite typically stays in the vagina and does not ascend into the uterus or tubes. It is fairly easily treated with a single 2g dose of Metronidazole by mouth.
Atrophic Vaginitis
When the vagina is post-menopausal, it loses the collagen and elastin in the deep dermis. The outside epidermal layer is only about 1/5 as thick as it is prior to menopause. The result is more burning with sexual intercourse, a kind of raw, burning sensation, sometimes accompanied by bleeding, and a tendency for the vagina to tear rather than stretch. This is typically reversed with topical vaginal estrogen. At Women’s Health Connection, we use vaginal estrogens that are known for staying local in the vagina (such as Vagifem and Estring), rather than ones that reach significant levels elsewhere in the body (such as Premarin or Estrace). The vagina is also more prone to infection of various kinds when it is this thin, and urinary urgency and frequency are usually associated with this condition. Treatment of atrophic vaginitis needs tob e on an ongoing basis after menopause, ie if you stop, the vagina returns to its atrophic state. Usually it takes a few months of using topical estrogen before significant changes are noticed.
To summarize, vaginitis has a variety of causes, all of which are usually relatively easy to treat once recognized. Sometimes a single course of treatment is adequate. Sometimes several courses are necessary.
