Vaginitis and Vulvovaginitis

Vaginitis is the medical term for inflammation or infection of the vagina (birth canal). It typically occurs when there is a decrease in the acidity (increase in pH level) of the vagina or an infection. In premenopausal women, the normal pH level of the vagina is approximately 4.0 on the 0 to 14 pH scale that goes from acid to alkaline. This acidity normally limits the development of infectious bacteria, fungi and parasites. Vaginitis may also result from reduced levels of estrogen that occur after menopause.

The glands inside the vagina and cervix (the bottom part of the uterus) produce small amounts of fluid. The fluid is discharged from the vagina daily, carrying out old cells that have been shed from the vaginal lining. This is the body’s way of ensuring that the vagina remains clean and healthy.

Vaginal discharge is typically clear or milky in appearance and odorless. The color and consistency of the discharge may change during menstruation and become thicker during ovulation, breastfeeding and sexual arousal. Other changes in the discharge, such as a difference in color or odor, often indicate that a woman has vaginitis or a sexually transmitted disease (STD).

There are several types of vaginitis. The three most common types are:

• Bacterial vaginosis (BV). Caused by an overgrowth of one of several organisms (bacteria) that are usually present in the vagina.
• Yeast infection (genital candidiasis). Caused by an overabundance of Candida, a microscopic fungus that normally inhabits the vagina.
• Trichomoniasis. Caused by a parasite in the vagina, typically the Trichomonas vaginalis.

Common indicators of vaginitis may include:

• Change in amount of vaginal discharge
• Change in color and/or odor of vaginal discharge
• Itching and/or burning inside or around the vagina
• Pain during vaginal intercourse (dyspareunia)
• Pain during urination (dysuria)
• Light bleeding from the vagina

Routine gynecological examinations can often identify vaginitis that is not accompanied by noticeable symptoms. Therefore, it is important for women to annually visit their gynecologist (a physician who specializes in treating disorders of the female reproductive system). Women who experience signs and symptoms of vaginitis should immediately notify their gynecologist unless they have been previously diagnosed with a yeast infection and the signs and symptoms are identical.

Diagnosis of vaginitis typically begins with a medical history, followed by a pelvic examination. Women should avoid douching or using deodorant sprays before their medical examination because these products can impede the diagnosis of vaginitis.

If bacterial vaginosis (BV) is suspected, the gynecologist will measure the acidity or pH level of the patient’s vagina using narrow-range pH paper. The normal vaginal pH of premenopausal women is approximately 4.0 on the 0 to 14 pH scale, with 7.0 being neutral. A pH of 4.5 or greater may indicate that the patient has BV. The gynecologist will also typically take a sample of the patient’s cervical or vaginal discharge for analysis under a microscope. The sample will be examined for “clue cells,” bacteria-covered cells in the patient’s vaginal lining that indicate the presence of BV. In addition, the gynecologist may add potassium hydrochloride to a vaginal discharge specimen and check its odor (whiff test).

Women who have had yeast infections in the past often believe that they can diagnose an infection without consulting their gynecologist. However, misdiagnosis of yeast infection is common. Therefore, women should schedule a gynecological appointment unless they are certain that they have a yeast infection, and not another condition that presents similar symptoms.

To diagnose a yeast infection, the gynecologist will examine the vagina for abnormal discharge or inflammation. The physician will also collect secretions from the vaginal area and view the specimens under a microscope to determine if the infection is present due to a yeast organism (slide test). This test is generally sufficient for diagnosing yeast infections in first-time sufferers and those with occasional infections. However, cases of recurrent or resistant yeast infections may require further analysis in the form of a vaginal culture, which is used to identify the presence of other forms of vaginitis as well as sexually transmitted diseases.

Trichomoniasis may also be detected by measuring the acidity or pH level of the patient’s vagina using pH paper. However, the condition is typically diagnosed by examining a vaginal fluid sample under a microscope for the presence of parasites (protozoa). This technique, called a “wet mount,” is accurate only about 50 percent of the time because the protozoa can be difficult to find, and are often mistaken for normal cells. Researchers are developing more reliable tests for diagnosing this condition.

Diagnosis of viral vaginitis typically depends on the type of virus present. For instance, the human papillomavirus (HPV) can sometimes be detected along with a Pap smear (a screening procedure that detects changes in the cervix) or through special DNA probe tests that can determine the type of HPV virus.

The main goal of treating all forms of vaginitis is symptom relief. Treatment of vaginitis depends on its type as well as the patient’s preference. For instance:

• Bacterial vaginosis (BV) can be treated with oral antibiotics, vaginal creams or vaginal gels prescribed by a physician. Treatment for BV is effective in most cases. If symptoms disappear, follow-up visits are not usually necessary. For recurrent cases, a more powerful antibiotic may be prescribed.
  
  During treatment for BV, women may be advised to refrain from sexual intercourse or ask male partners to use condoms. Routine treatment of male sexual partners is not usually necessary. Pregnant women who are symptomatic for BV, or have previously delivered a premature baby, should be screened and tested for the condition during their first prenatal visit. Pregnant women with symptomatic BV should be treated in the beginning of the second trimester with oral medication only. There is controversy regarding the treatment of pregnant women with nonsymptomatic BV.
  
  
• Yeast infections can be treated with antifungal creams, vaginal suppositories or oral antifungal medication. Creams and suppositories can be purchased over-the-counter (OTC). However, a physician must prescribe oral medication. Patients should seek medical advice before using OTC products if they:
  • Have not previously had a yeast infection
  • Have abdominal pain and/or fever
  • Are pregnant or nursing
  • Have diabetes or human immunodeficiency virus (HIV)
  • Used an OTC treatment but symptoms did not disappear or returned immediately
  
  Women may be advised to refrain from sexual intercourse while being treated for a yeast infection. Treatment can last anywhere from one to 14 days. Yeast infections generally respond to treatment within a few days. Routine treatment of male sexual partners is generally not recommended.
  
  
• Trichomoniasis is typically treated with oral medication (antibiotics) prescribed by a physician. Routine treatment of male sexual partners is advisable otherwise reinfection will likely occur. A follow-up visit is not necessary if symptoms were not evident before treatment or disappear afterward.
• Atrophic vaginitis can be treated with estrogen replacement therapy (ERT) in oral form, or in the form of a transdermal patch, vaginal rings, tablets or creams. ERT is prescribed by a physician.
• Noninfectious vaginitis can be treated by identifying and avoiding the source of the irritation (e.g., perfumed soaps, deodorized tampons).