Vaginal Infections Overview

Vaginal infections, or vaginitis is an inflammation of the vagina that creates discharge, odor, irritation, or itching. It is difficult to diagnose because vaginitis has many causes. Women use a variety of over-the-counter medications to treat the itching, discharge, and discomfort of these conditions.

• The vagina creates its own environment and maintains a balance among the normal bacteria found there and the hormonal changes in a woman's body. Vaginitis occurs when the vaginal ecosystem has been changed by certain medications such as antibiotics, hormones,contraceptive preparations (oral and topical), douches, vaginal medication, sexual intercourse, sexually transmitted diseases, stress, and change in sexual partners.

• Some vaginal infections are transmitted through sexual contact, but others such as yeast infections probably are not. Vaginitis means inflammation and is often caused by infections, but may be due to hormonal changes (especially when a woman is going throughmenopause) or due to trauma in young girls. Some infections are associated with more serious diseases.
• Three types of vaginal infections are the most common. Their causes are quite different but, their signs and symptoms are similar, and treatments of the three conditions vary.

1. Bacterial vaginosis
2. Vaginal yeast infection
3. Trichomoniasis

• Many women often mistakenly think they have a "yeast infection" and treat themselves when, in fact, they have a similar vaginal infection that will not respond to self-treatment with over-the-counter yeast medications. A study by the American Social Health Association found that 70% of women self-treated vaginal infections before calling a health care provider. Most often, they incorrectly thought they had ayeast infection when, in fact, it was bacterial vaginosis or another condition.

• The important thing is not to guess, but to recognize the symptoms if you develop a vaginal infection. If you have any concerns, see your health care practitioner for precise testing and to get the most appropriate and effective treatment right away.Bacterial vaginosis (BV) is the most common cause of vaginitis, accounting for 50% of cases. Bacterial vaginosis is caused by a change or imbalance in the types of the bacteria normally found in the vagina and causes an overgrowth of organisms such as Gardnerella vaginalis.
  • Risk factors include pregnancy,intrauterine device (IUD) use, and frequent douching. It is associated with sexual activity, and possibly a new sexual partner or multiple sexual partners. Women who have never had sexual intercourse are rarely affected.
  • You do not get bacterial vaginosis from toilet seats, bedding, or swimming pools.
  • In the United States, as many as 16% of pregnant women have bacterial vaginosis. This varies by race and ethnicity from 6% in Asians and 9% in whites to 16% in Hispanics and 23% in African Americans.
  Vaginal yeast infections are caused by a fungus, mainly by Candida albicans. This is also called candidiasis, genital candidiasis, or vulvovaginal candidiasis (VVC). Yeast infection can spread to other parts of the body including skin, mucous membranes, heart valves,esophagus, and other areas. In rare circumstances, it can cause life-threatening systemic infections mostly in people with weakened immune defenses (such as women who are pregnant and people who are HIV positive, have diabetes, or are taking steroids).
  • A majority of adult women have had at least one genital yeast infection in their lifetime. Vaginal yeast infection is not considered a sexually transmitted disease, but some men will develop symptoms such as itching and penile rash following sexual contact with an infected partner.
  • Yeast infections are caused by an overgrowth of normally growing fungi in the vagina that creates unpleasant symptoms. The yeast are normally kept under control by naturally occurring bacteria in the body. If the natural balance of microorganisms is disrupted, the yeast grow out of control. It is not clear how fungal infections originate, but they are not thought to be sexually transmitted. Infections tend to happen when an imbalance occurs, possibly caused by any of these events:
  • Use of antibiotics: Antibiotics destroy protective bacteria in the vagina. These bacteria normally stop the candidal organisms from overgrowing. Yeast infection may occur after taking a course of antibiotics for another condition such as strep throat.
  • Diabetes or pregnancy: Both diabetes and pregnancy make the vagina better suited for fungal growth. These conditions lower the glycogen store in certain vaginal cells. They may also raise the sugar content (and the pH) of the vagina and increase the risk of yeast infection.
  • Birth control pills: Changes in the vaginal environment occur with increased hormonal levels from estrogen-containing birth control pills. This change creates an environment for the fungus to grow and cause symptoms.
    • Hormonal changes such as ovulation, menopause, or pregnancy
    • Steroid use
    • Wearing underwear that is tight or non-cotton: This can increase temperature, moisture, and local irritation.
    • Weakened immune system: HIV/AIDS, for example
    • Use of douches, perfumed feminine hygiene sprays
    • Scratches in the vagina (during insertion of a tampon or other objects)
  • Trichomoniasis is a sexually transmitted disease (also called trich, pronounced "trick") caused by the parasite Trichomonas vaginalis. Trichomoniasis is primarily an infection of the urinary and genital tract. For women, the vagina is the most common site of infection. For men, the urethra is most commonly affected.
  • Other causes of vaginal inflammation may be allergies to spermicides, vaginal hygiene products, and detergents and fabric softeners. Another type of sexually transmitted disease may be present. Older women may experience atrophic vaginitis (a thinning of the vaginal walls with menopause). Foreign objects such as a forgotten tampon or another foreign object may cause vaginal irritation.Vaginal discharge, itching, and burning are common symptoms of the various forms of vaginitis. Although the symptoms of these infections can be very similar, there are some differences to look for in the color and smell of the discharge.
    Some vaginal discharge is quite common and normal for women of childbearing age. Normally, cervical glands produce a clear mucous secretion that drains downward, mixing with bacteria, discarded vaginal cells, and Bartholin's gland secretions at the opening of the vagina. These substances may (depending on how much mucus there is) turn the mucus a whitish color, and the discharge turns yellowish when exposed to air. There are times throughout the menstrual cycle that the cervical glands produce more mucus than others, depending on the amount of estrogen produced. This is normal.
    Sexual excitement and emotional stress have both been associated with a normal vaginal discharge. This discharge is a clear, mucus-like secretion.
    If your vaginal discharge is abnormal in color such as green, has a foul smell, changes consistency, or is significantly increased or decreased in amount, you may be developing a form of vaginitis.
    • Bacterial vaginosis (BV) causes an abnormal vaginal discharge with an unpleasant odor. Some women report a strong fishy smell, especially after intercourse. The discharge is usually white or gray, and it can be thin. You may also have burning during urination or itching around the outside of the vagina, or both. Some women with bacterial vaginosis have no symptoms at all.
    • Yeast infections or candidiasis cause a thick, whitish-gray "cottage cheese" type of vaginal discharge and may be itchy. You may have intense itching in your genital area. Painful urination and intercourse are common. You may not always have a vaginal discharge. Men with genital candidiasis may have an itchy rash on the penis. Most male partners of women with yeast infection do not experience any symptoms of the infection.
    • Trichomoniasis causes a frothy vaginal discharge that may be yellow-green or gray, itching and irritation of the genitals, burning with urination (sometimes confused with a urinary tract infection), discomfort during intercourse, and a foul smell. Because trichomoniasis is a sexually-transmitted disease, symptoms may appear within 4-20 days after exposure. Men rarely have symptoms, but if they do, they may have a thin, whitish discharge from the penis and painful or difficult urination.
    • Pain itself is not a frequent symptom of vaginal infections (except for the itching) and should prompt you to see your health care practitioner.
    • If you have a condition called vulvodynia, you may have burning, stinging, irritation, or rawness of your genitalia but no infection or skin disease of the vulva or vagina. You may have pain, off and on. This is a different condition that requires further management with your health care practitioner

      When to Seek Medical Care

      You should seek medical care any time if you have pain. Although vaginal infections may cause unpleasant itching, they should not cause pain.
      Call for an appointment with your health care practitioner if this is the first time that vaginal yeast infection symptoms have occurred, or if you are unsure if you have a yeast infection. (If you are sure that you have a yeast infection, you can treat the disorder with over-the-counter medications.) If your symptoms do not respond to one course of over-the-counter medications, you may not have a yeast infection and you should see your doctor.
      Vaginal yeast infections, although uncomfortable, are usually not life-threatening. You should see your health care provider. In addition, seek care for any of the following:
      • Foul-smelling or yellow vaginal discharge
      • Any stomach or back pain
      • Vomiting or fevers
      • If symptoms return within two months
      • Other pelvic conditions with symptoms similar to vaginal yeast infections need to be checked by a health care practitioner in a hospital's emergency department. Seek medical care if the following conditions develop:
        • If you have vaginal discharge associated with fever, vomiting, andabdominal pain or if you have vaginal discharge accompanied by vaginal bleeding that is not a normal menstrual period, you may go to a hospital's emergency department.
        • Your symptoms have not improved in three days, a large amount of vaginal discharge is seen, or if initial symptoms worsen.
        • You have greenish or large amounts of discharge or fever.
        • You have been taking antifungal medications for a yeast infection and you develop yellow skin, yellow eyes (the white part is yellow), or pale stools.
        • Lesions or rash develop elsewhere (tender, red, pus-filled bumps, which can spread to the thighs and anus).
        • Dizziness develops.

          Vaginal Infection Diagnosis

          Your health care practitioner will ask about your symptoms and perform a physical exam. Urine tests and samples of any discharge will likely be done.
          • You may be asked questions including the following:
          • When did this condition begin? Has the discharge been the same throughout the month?
          • What does the discharge look like? What colour and consistency? Is there an odour?
          • Do you have pain, itching, or burning?
          • Does your sexual partner, if you have one, have discharge from his penis?
          • Do you have many sexual partners?
          • Do you use condoms?
          • What helps relieve the discharge? Do you take frequent baths? Have you tried over-the-counter medications? Douching?
          • What other symptoms do you have?
          • What medications do you take for all conditions?
          • Have you changed detergents or soaps you use?
          • Do you often wear tight underwear or pants/jeans?
          • During the pelvic examination, the doctor will inspect your vagina and cervix for any discharge or sores. The doctor will determine the size and location of the uterus and cervix. The doctor will assess if you have pain or tenderness on movement of the cervix and uterus, or in the areas next to the uterus, which correspond to the Fallopian tubes and ovaries.
          • During the vaginal examination, a speculum is introduced into the vagina to see the cervix. Swabs will be taken of any discharge to determine if the infection is fungal (yeast), protozoan (trichomoniasis), or bacterial (bacterial vaginosis). Your health care provider can examine a sample of vaginal discharge under a microscope to detect the presence of the organisms associated with vaginal infections.
          • In some cases, a Pap test will be performed to exclude the possibility of cervical cancer. This test is sent to the laboratory, and results are usually obtained within one week.
          • Newer DNA-based tests are quite accurate for diagnosing vaginal infections.
          • A colposcopy or biopsy might be recommended if your cervix appears abnormal. Colposcopy uses a lighted microscope to get a magnified view of the surface of the cervix. In a biopsy, a tissue sample is taken for testing.
          • Certain blood tests can detect antibodies to the yeast-infection causing Candida albicans. This test is not very reliable for vaginal infections and is only useful in people who have an infection that affects their whole body.
          • If trichomonas is present, and confirmed by laboratory tests, your doctor may do more tests for other sexually transmitted diseases (STDs)

            Vaginal Infections Treatment

            Diagnosis is usually made based on your symptoms and results of urine tests and vaginal cultures (samples checked in the lab). Treatment is based on the organism causing the infection. Depending on the cause of the infection, your health care practitioner may prescribe vaginal suppositories, antifungal pills, or antibiotics (as pills or an injection). Treatment varies depending on which form of vaginitis you have, the severity of infection, duration of infection, recurrence of infection, and whether you are pregnant. 

            Vaginal Infection Self-Care

            
            Only yeast infections may respond to over-the-counter medications. If you have never had a yeast infection and think you have one, it is important that your health care provider agrees with this diagnosis before you try any home care techniques or over-the-counter medications. Generally, the first incidence of yeast infection should be treated by your health care provider.Bacterial vaginosis and trichomoniasis will not go away with home care or over-the-counter medications. They  require antibiotics. You must see your health care provider.
            • After the first infection, if a second infection occurs and you have no doubt it is a yeast infection, you may treat yourself with one course of over-the-counter vaginal medication, such as miconazole (brand name Monistat and others), an antifungal vaginal medication.
            • Because over-the-counter treatments have become available, many women diagnose themselves with a yeast infection, when, in fact, about two-thirds of all remedies purchased in stores to treat yeast infection were used by women who did not really have one. Using these drugs when they are not needed may lead to a resistant infection. Resistant infections are very difficult to treat with the currently available medications. If in doubt, consult your health care provider.
            • Many current over-the-counter medications are available for mild cases of yeast infection. The cure rates with the nonprescription drugs are about 75%-90%.
            • The medications are sold as vaginal suppositories or creams. They are inserted into the vagina with a plunger-type applicator and are usually used one each day for seven days. Stronger doses are given over one to three days only. Most women can treat yeast infections at home with these medications:
              • miconazole (Monistat-7, M-Zole)
              • tioconazole (Vagistat Vaginal)
              • butoconazole (Femstat)
              • clotrimazole (Femizole-7, Gyne-Lotrimin)
            • Massage these remedies into your vagina and surrounding tissues for one to seven days or insert the suppository form into your vagina, depending on the formulation and instructions. If increased irritation occurs to the area, discontinue the medication immediately.
            • If you are pregnant, consult your doctor before using these treatments.
            • If symptoms continue for more than 1 week, consult your doctor. You may have a severe yeast infection or other problems that mimic a yeast infection.
            • Home care techniques have been used for many years although scientific studies have not proven their effectiveness.
              • Vinegar douches: While many women use a douche to clean themselves after menstrual periods or sexual intercourse, doctors discourage such routine cleansing. The vagina is made to cleanse itself. Douching may disrupt the healthy bacteria lining the vagina. By attempting to treat an abnormal vaginal discharge by douching, you might actually worsen the condition. Do not douche without your health care provider's knowledge when you have an abnormal discharge, and do not douche for 24 hours prior to seeing the doctor.
              • Eating yogurt that contains live acidophilus cultures (or eating acidophilus capsules): Yogurt acts as a medium for certain good bacteria to thrive. Despite popular belief, studies about the benefits of eating yogurt with lactobacillus acidophilus cultures as a way to prevent yeast infection have yielded conflicting results. The scientific benefit of consuming yogurt cultures has not yet been proven.
              • Other products available over-the-counter contain antihistamines or topical anesthetics (numbing medications) that only mask the symptoms and do not treat the underlying problem.Bacterial vaginosis: Your health care provider may treat you with antibiotics such as metronidazole (Flagyl) or clindamycin (Cleocin). Generally, male sex partners are not treated. Many women with symptoms of bacterial vaginosis do not seek medical treatment, and many women without symptoms decline treatment. This condition may resolve spontaneously in up to one third of cases in non-pregnant patients and up to half in pregnant patients.
                Yeast infection: If this is the first time you have had a yeast infection, a doctor should be consulted before trying any home remedies or over-the-counter products. Your doctor will usually recommend that you use vaginal creams and vaginal applications rather than oral medication. Pregnant women usually will be treated longer than nonpregnant women and be closely monitored.
                • Severe infections need antifungal medication, which is normally taken orally as a single dose. This could include fluconazole (Diflucan) and itraconazole (Sporanox). These drugs have a cure rate of greater than 80%. These medications can also be given for three to five days with similar cure rates. The medications might cause liver problems. Some of the symptoms of liver problems are yellow skin, yellow eyes, and pale stools. If you have any of these signs, contact your doctor right away. Your doctor will probably advise you to stop the medication immediately, perform blood tests, and monitor your liver functions.
                • For less severe infections, medications can be used as a vaginal tablet or cream applicator. One example is nystatin (Mycostatin), with a cure rate of about 75%-80%. Miconazole (Monistat-7, M-Zole) and clotrimazole (Mycelex, Gyne-Lotrimin) have a cure rate of about 85%-90%.
                • In some cases, a single dose of medication has been shown to clear up yeast infections. In other cases, a longer period of medication (three days or seven days) might be prescribed.
                • For recurrent infection (more than four episodes per year), oral fluconazole and itraconazole or vaginal clotrimazole might be needed for six months.
                • In pregnant women, a longer course of treatment is needed. It is very important to consult with your doctor before treatment.
                Trichomoniasis: Trichomoniasis is treated with metronidazole. It usually is given in a single dose. If you take this drug, do not drink alcohol because mixing the two substances occasionally can cause severe nausea and vomiting. Both sex partners are treated with the medicine even if they do not have signs of the disease.

                Next Steps

                If you are diagnosed with vaginitis, keep your genital area clean and dry. Take showers instead of baths. This will also help prevent future infections. Don't douche or use feminine hygiene sprays or powders while being treated. Don't have sexual relations while being treated.
                After you leave the doctor, abstain from sexual intercourse until treatment is completed and symptoms subside. 

                Follow-up for Vaginal Infection

                Follow up with your doctor for results of your cervical lab tests and Pap test. It is recommended that you have a complete physical examination every year, whether or not you are experiencing any symptoms.
                • Because the bacterial balance of the vagina is very sensitive, it is best to let the vagina clean itself. The vagina takes care of cleaning itself naturally through secretions of mucus. Warm water and gentle, unscented soap during the bath or shower is the best way to clean the outside areas of the vagina. Products like feminine hygiene soaps, powders and sprays are not necessary, and may be harmful.
                • Douching is rinsing or cleaning out the vagina by squirting water or other solutions (such as vinegar, baking soda, or douching solutions you can buy at drug and grocery stores) into the vagina. The water or solutions are held in a bottle and squirted into the vagina through tubing and a nozzle. Although douching is a common practice among women in the United States, health care providers do not recommend douching to clean the vagina. Douching changes the delicate balance in the vagina, which can make you more likely to develop a vaginal infection. Research shows that women who douche regularly tend to have more problems such as vaginal infections than women who do not douche or who rarely douche.
                • Douching is not a form of birth control, and douching after sex does not prevent pregnancy. 

                  Vaginal Infection Prevention

                  • The best ways to prevent bacterial vaginosis are not known. However, enough is known to show that bacterial vaginosis is associated with having a new sex partner or having multiple sex partners. It is seldom found in women who have never had intercourse. Basic prevention would include using condoms, limiting the number of sex partners, abstaining from douching, and using all the medicine prescribed for treatment of bacterial vaginosis, even if the symptoms go away.
                  • Vaginal yeast infections can be easily prevented in most cases.
                  • Keep your vaginal area dry, especially after a shower.
                  • Wipe from front to rear after using the toilet.
                  • Switch to looser-fitting cotton underwear.
                  • Change wet bathing suits after a swim.
                  • Avoid tight-fitting jeans or pantyhose.
                  • Pregnant women should see their doctor immediately if they are experiencing symptoms.
                  • Avoid chemical irritants in deodorized tampons. Do not use douches or feminine hygiene products. Regular bathing is usually adequate to cleanse the vagina.
                  • Trichomoniasis can be prevented. If you are diagnosed with a trichomonal infection, your sex partner should also be checked. He or she may have other sexually transmitted diseases and also may re-infect you if not treated. Safe sex with condoms and counseling about sexually transmitted diseases may help decrease the rates of infection and reinfection.

                    Vaginal Infection Prognosis

                    If diagnosed and treated correctly, all forms of vaginitis usually respond well to therapy. Your symptoms will clear up and go away. If your symptoms won't go away or the symptoms come back, you must be reevaluated by your health care provider.
                    • Bacterial vaginosis is associated with pelvic inflammatory disease (PID), which can cause infertility and tubal (ectopic) pregnancy. Bacterial vaginosis also can cause problems with pregnancy such as premature delivery and low-birth-weight infants.Your health care provider will be monitoring your condition closely if you are pregnant and have had a premature baby before. Bacterial vaginosis may also put you at increased risk of gonorrhea and HIV infection.
                    • Trichomoniasis is associated with increased risk of transmission of HIV and may cause a woman to deliver a low-birth-weight or premature infant.