Vaginitis

What is Vaginitis?

Many women often experience vaginal symptoms like discharge, irritation, and itching. These symptoms are frequently associated with a condition called vaginitis, a common issue seen by doctors. To correctly identify if there is a problem, doctors must first understand what normal vaginal health looks like. Once they know this, they can more easily spot when something isn’t quite right and decide if treatment is needed.

Maintaining a balanced mix of microorganisms, or tiny living things, in the vagina is crucial for overall health, especially for reproductive health. However, it’s still a hot topic among medical experts about what makes up a “normal” balance as compared to an “imbalanced” one, referred to as dysbiosis.

Adding to the complexity, women from different ethnic backgrounds have unique combinations of microorganisms in their vaginas, and these can even differ based on the region. Also, many factors influence this balance, including things like pregnancy, menstrual cycles, sexual behaviors, age, and birth control methods.

Generally, the vaginal balance in many women is dominated by a type of bacteria called lactobacilli. These good bacteria have protective benefits, acting as a shield against potentially harmful ones, and thereby lowering the risk of urinary tract and sexually transmitted infections.

What Causes Vaginitis?

The lining of the vagina is sensitive to hormones, and it’s made up of layers of cells that are not hardened or covered in a protective layer of skin. The normal bacteria that live in the vagina of women of reproductive age include both types that need oxygen to survive and those that don’t. There are over 50 different kinds of bacteria that are usually found in the vagina, although the most common type is lactobacilli. In fact, there are usually 10 times more bacteria types that don’t need oxygen than those that do. These bacteria have a mutually beneficial relationship with your body and can change based on the environment inside your vagina. Researchers from around the world have conducted studies to understand the composition of the vaginal bacteria in different regions, concluding that what’s considered normal can vary from one place to another.

Here is a list of typical bacteria found in the vagina:

Bacteria that need oxygen (Gram-positive aerobes):

* Lactobacillus
* Diphtheroids
* Staphylococcus aureus
* Staphylococcus epidermidis
* Group B Streptococci
* Enterococcus faecalis
* Staphylococcus spp

Bacteria that need oxygen (Gram-negative aerobes):

* Escherichia coli
* Klebsiella species
* Proteus species
* Enterobacter species
* Acinetobacter species
* Citrobacter species
* Pseudomonas species

Bacteria that don’t need oxygen (Gram-negative anaerobes):

* Prevotella species
* Bacteroides species
* Bacteriodes fragillis species
* Fusobacterium species
* Veillonella species

Bacteria that don’t need oxygen and are sphere-shaped (Anaerobic gram-positive cocci):

* Peptostreptococcus species
* Clostridium species

Bacteria that don’t need oxygen and are rod-shaped (Anaerobic gram-positive bacilli):

* Lactobacillus species
* Propionibacterium species
* Eubacterium species
* Bifidobacterium species
* Actinomyces israelii

Believe it or not, these bacteria help maintain the normal acidity of the vagina. In girls who haven’t gone through puberty and women who’ve passed menopause, a lack of estrogen means they also have less glycogen, which decreases the number of bacteria that produce lactic acid (like Lactobacilli). These women have a vaginal pH of 6 to 7.5, and susceptible to infections because most of the bacteria are mainly from the skin. Among these women, inflammation of the vulva and vagina (vulvovaginitis) is quite common. But during their reproductive years, the higher levels of estrogen enable the vagina to produce glycogen, which many vaginal bacteria need as a nutrient, including Lactobacillus. This bacteria converts glycogen to lactic acid, thereby contributing to the normal vaginal pH of 3.8 to 4.2. This acidity helps suppress the excessive growth of infectious organisms.

However, any change in the vaginal environment can affect its bacterial makeup. Hormonal changes during menopause, pregnancy, and breastfeeding can greatly influence these bacteria. While menstrual fluid can act as a food source for some bacteria, there’s no strong evidence linking it to harmful microbial growth. Broad-spectrum antibiotics can change the bacterial balance and cause an overgrowth of Candida (yeast). Other activities like douching, unprotected sex, using strong soaps, scented feminine products, or wearing tight clothing can raise the vaginal pH, potentially causing vaginitis (inflammation of the vagina).

Risk Factors and Frequency for Vaginitis

Vaginitis is a highly common condition affecting millions of women every year around the globe. The most frequent cause is bacterial vaginosis, making up 40% to 50% of cases. Another common cause is yeast infections, which affect about 20% to 25% of women at least once in their life. Trichomoniasis, which is a sexually transmitted infection, affects roughly 8 million US women annually.

The frequency of vaginitis can change based on a woman’s age, sexual activity, and hormonal state. The incidence is higher in women of reproductive age and during times of hormonal shifts like pregnancy and menopause. Various factors can influence the normal bacteria found in the vagina, including physiological, environmental, social and economic factors, as well as hygiene practices and healthcare access.

Approximately 8% of White women and 18% of Black women report symptoms like vaginal discharge, odor, itchiness, and discomfort each year. Over half of these women consult a healthcare professional when the symptoms occur, but many use over-the-counter antifungal treatments at home.

• Bacterial Vaginosis: The most common cause of vaginitis in women of reproductive age is bacterial vaginosis, resulting from a change in normal vaginal bacteria. Symptoms include foul-smelling discharge, vaginal irritation, and sometimes a burning sensation during urination.
• Vaginal Candidiasis: An overgrowth of the Candida fungi causes Candida vaginitis. This type of vaginitis affects 55% of women by the age of 25 and comprises the second most common type after bacterial vaginosis.
• Trichomoniasis: The most frequent nonviral sexually transmitted infection is Trichomonas vaginalis, affecting over 1 million people in the US every year. The incidence of this infection worldwide is reported at 153 million cases. Various factors, including age, race, income, social and economic factors, and education level, contribute to the global epidemiology of trichomoniasis.
• Desquamative Inflammatory Vaginitis: This is a chronic, noninfectious, inflammatory condition that involves severe inflammation of the vaginal lining. Symptoms include heavy, pus-filled vaginal discharge, along with intense itchiness and a burning sensation in the vulvovaginal area.
• Atrophic Vaginitis: Also known as genitourinary syndrome of menopause, this condition affects a significant portion of menopausal women, causing symptoms like vaginal dryness, inflammation, thinning of vaginal skin, and sometimes pus-filled discharge.
• Mixed Vaginitis: This is a condition where two or more vaginal pathogens are present at the same time, leading to atypical symptoms and a more complicated treatment process. The three most common types include DIV with atrophic vaginitis and bacterial vaginosis, vulvovaginal candidiasis with DIV or atrophic vaginitis, and vulvovaginal candidiasis with bacterial vaginosis.

Signs and Symptoms of Vaginitis

Diagnosing a condition like vaginitis requires a complete medical history and physical exam. This thorough check-up helps the doctor understand the root cause of the symptoms and decide on the best course of treatment.

Vaginal secretions, under normal conditions, help to maintain a healthy vagina by getting rid of dead cells and bacteria. Throughout the menstrual cycle, these secretions can vary in terms of look, thickness, quantity, and even odor. Typically, they are clear or slightly white, have a thin to somewhat thick, mucous-like consistency, and carry a light smell. Around ovulation, these secretions might increase and become clearer and stretchy, promoting fertility. With a usual pH ranging between 3.8 and 4.5, vaginal secretions also assist in preventing infections by maintaining the vagina’s acidic surroundings. Itching, burning, or irritation signifying an abnormal color, consistency, odor, or drastic changes should call for a medical check-up.

When experiencing symptoms like unusual vaginal discharge, itching, irritation, smell, discomfort during urination or intercourse, it’s time to seek evaluation. The examining physician will begin with a detailed history focused on the nature and timing of the symptoms. This includes asking about any past occurrences, vulvovaginal hygiene habits like the use of lubricants, shaving, and douching. It’s also important to document a complete sexual history, including prior STIs, and to look into any new potential allergen exposure. Any self-medication attempts should also be recorded. Also, the patient’s medical history, especially immune suppression and other relevant health conditions, should be reviewed.

The physical exam typically starts with a careful evaluation of the vulva and surrounding skin for any redness or swelling. Noting the visual characteristics of the vaginal discharge is an important procedure, even though it is not diagnostic on its own. Testing the pH of the discharge is also necessary. This is usually done by taking a sample from the mid portion of the vaginal sidewall, as cervical mucus, semen and blood can falsely increase the pH.

Testing for Vaginitis

When a woman experiences vaginal symptoms, several tests can help identify the cause. These include pH testing, a potassium hydroxide “sniff test,” and a microscopic examination using saline and a potassium hydroxide solution. Certain tests that the US Food and Drug Administration approves may also be used.

“Liquid Mount Microscopy” is a test where doctors try to determine the best location to sample vaginal discharge. The best results come from taking samples from various sites in the vagina, particularly the lower portion. It’s important to avoid touching the cervix during sampling to prevent contamination. The sample is taken with a special brush, spatula, or swab to ensure accuracy. In some cases, patients may even collect the sample themselves.

The sample is placed on a slide, sometimes mixed with a small drop of saline and then covered with a glass covering. It’s key not to have any air bubbles. Some doctors may use a drop of 10% potassium hydroxide solution to highlight fungal structures. Within 10 minutes of sampling, the slide should be viewed under a high-power microscope to count organisms and cells.

The slide will feature various cells that give doctors clues about the woman’s health. For example, “Squamous epithelial cells” are found in healthy women’s vaginal secretions. However, if these cells are covered in bacteria, called “clue cells,” it suggests an overgrowth of a certain bacterium. White blood cells are typically present in small amounts, but an increased presence could indicate various infections. Additionally, nurses look for other cells and organisms associated with different health conditions.

A separate slide receives the potassium hydroxide prep with the saline-diluted specimen. This test helps identify certain bacteria. Yeast cells are carefully examined to search for signs of a yeast infection.

Other diagnostic tests are rare but can pinpoint the specific bacteria causing an infection. For example, a “Gram Stain” is evaluated using a scoring system, but it’s typically used only in research. Additionally, “Cell culture” is great for detecting yeast but isn’t timely or helpful for other bacteria.

Modern techniques include “DNA Technologies,” which can quickly identify specific bacteria with high sensitivity. These tests, and some point-of-care options, can provide results within minutes.

Conditions like “Desquamative Inflammatory Vaginitis” and “Atrophic Vaginitis” can cause different symptoms and are diagnosed using a combination of physical exam and microscopic analysis. They’re typically identified by features such as inflammation, abnormalities in normal cells, and other signs viewed under a microscope.

Finally, “Mixed Vaginitis” can cause a variety of symptoms. Most commonly, women report changes in discharge, itching, and a burning sensation.

Treatment Options for Vaginitis

Vaginitis, which is inflammation of the vagina, needs to be treated based on its specific cause. Different treatments are suggested for different types of vaginitis.

Bacterial vaginosis, one type of vaginitis, can be treated with medication like metronidazole or clindamycin. It’s no longer necessary to avoid alcohol while taking metronidazole. About 80% to 90% of people should see improvement about a week after treatment. Future check-ups aren’t necessary unless symptoms come back. If bacterial vaginosis does come back, the same treatment can be repeated or an alternative regimen can be used.

Another type, trichomoniasis, can be treated with metronidazole or tinidazole pills. These are the only types of medication that effectively treat this kind of infection. Cure rates are generally high. If standard treatments fail, you may need to see an infectious disease specialist.

Yeast vulvovaginitis is another common type of vaginitis, often caused by Candida species. Risk factors for this infection include using antibiotics or hormonal contraceptives, pregnancy, diabetes, and having a weakened immune system. Symptoms can include burning, itchiness, pain during sex or when urinating, and a thick, white discharge. Over-the-counter topical antifungals or a single oral dose of fluconazole are typically effective. If these don’t work, an expert might be needed.

Desquamative inflammatory vaginitis could be helped with topical steroids to reduce inflammation. If bacteria are suspected to be the cause, antibiotics may be prescribed. Treatments like clindamycin cream or hydrocortisone suppositories might be tried. Longer therapy could be needed, and estrogen therapy may help, particularly in postmenopausal women. Regular check-ups are important as this form of vaginitis often requires long-term management.

Atrophic vaginitis, often related to a lack of estrogen, could be helped by using lubrication during sex and vaginal moisturizers. If these don’t work, a doctor may suggest local vaginal estrogen therapy or a medication called intravaginal dehydroepiandrosterone. More recently, a selective estrogen receptor medicine called ospemifene has been approved for this condition.

Lastly, mixed vaginitis, which is caused by two or more vaginal pathogens, can be particularly challenging to treat. Each cause needs to be addressed. Some small studies have shown that a topical medication called fenticonazole can effectively treat mixed bacterial and fungal vaginitis. All the suggested treatments have to be discussed with your treating physicians and the right treatment regimen will be chosen after careful evaluation of your health status.

What else can Vaginitis be?

If a patient has symptoms similar to vaginitis, doctors need to consider a range of possible causes. This is to make sure they diagnose the problem correctly and treat it appropriately. Some conditions can mimic the symptoms of vaginitis are:

• Sexually Transmitted Infections:
• Chlamydia and Gonorrhea: They can cause discharge, irritation, and discomfort.
• Herpes Simplex Virus: This can cause pain, itching, and sores, similar to vaginitis.
• Human Papillomavirus: Some types can cause changes in discharge and genital warts.
• Urinary Tract Infections: They can cause a burning sensation during urination and a frequent need to urinate, which may be mistaken for vaginitis.
• Pelvic Inflammatory Disease: This can cause lower abdominal pain, fever, and unusual discharge, similar to vaginitis.
• Dermatologic (Skin) Conditions:
• Lichen sclerosus and lichen planus: Chronic skin conditions which can cause itching, discomfort, and skin changes that may be mistaken for vaginitis.
• Eczema and psoriasis: These conditions can cause irritation and itching in the genital area.
• Vulvodynia: Chronic vulva pain or discomfort can be mistaken for vaginitis symptoms.
• Allergic reactions to products: Things like soaps, detergents, or feminine hygiene products can lead to irritation and discharge similar to vaginitis.
• Foreign Bodies: Things left in the vagina, like tampons, can cause discharge, odor, irritation, and infection.

What to expect with Vaginitis

In most cases, women experiencing vaginitis – that is inflammation of the vagina – have a high likelihood of getting better. The most common forms of vaginitis, like bacterial vaginosis, yeast infections, and trichomoniasis, often improve with a course of antibiotics or antifungal medicines, depending on the root cause of the inflammation.

However, there’s a chance of the infection returning, and this can lead to uncomfortable symptoms like skin sores, constant irritation, and even scarring. Additionally, these issues can cause low sexual desire and impair sexual function.

Experiencing emotional stress and psychosocial issues is not unusual for women with vaginitis. Certain risk factors like a weakened immune system or ongoing exposure to irritants can impact the likelihood of vaginitis returning.

Early diagnosis and quick treatment are key to improving the chances of recovery and avoiding complications. A condition called atrophic vaginitis, which is part of the genitourinary syndrome of menopause – a collection of symptoms related to the urinary and genital areas during menopause – affects up to 77% of women. The severity of this condition can increase over time and can last for life.

However, local treatments can reduce the severity of symptoms by up to 80%, and the chances of full recovery are excellent with continued treatment.

On the other hand, desquamative inflammatory vaginitis, a chronic inflammation of the vagina, can be hard to diagnose and does not respond very well to existing treatments. The likelihood of being fully cured stands at just under 35% after two years, and a relapse is common. In fact, over half of the women with this condition may need ongoing therapy.

Possible Complications When Diagnosed with Vaginitis

If vaginitis is not treated or cared for correctly, it can lead to several health problems. For instance, it can result in PID (pelvic inflammatory disease), a potential consequence of untreated bacterial vaginosis or sexually transmitted infections (STIs) like trichomoniasis. PID could further lead to persistent pelvic pain, ectopic pregnancy (a pregnancy that develops outside the womb), and infertility.

Moreover, vaginitis heightens the risk of not only getting but also passing on STIs, including HIV. This happens when the infections disturb the normal protective lining and defense system of your vagina.

If you’re pregnant, bacterial vaginosis or trichomoniasis could lead to premature delivery, low birth weight of your baby, or an infection in the amniotic fluid (the liquid that surrounds and protects your baby in your womb) known as chorioamnionitis. Each of these scenarios poses risks to both you and your baby.

Ongoing vaginitis can also cause persistent symptoms like itching, burning, and discomfort, which can affect your daily activities, including sexual intercourse. It can lead to stress and issues in your personal relationship. Also, constant inflammation and irritation can harm vulvar and vaginal tissues, which makes you more prone to other infections and skin problems.

Additionally, the effects aren’t limited to physical health. Psychological impacts like anxiety, depression, and decrease in sexual self-esteem can also arise. A wrong diagnosis or treatment may worsen your symptoms and lead to the unnecessary use of antibiotics, which in turn increases the likelihood of bacterial resistance to these antibiotics.

That’s why it’s crucial to get the right diagnosis promptly, undergo proper treatment, and adopt preventive measures to avert these complications.

Problems related to untreated or poorly managed vaginitis include:

• PID leading to chronic pelvic pain, ectopic pregnancy, and infertility
• Increased risk of contracting and transmitting STIs, including HIV
• Preterm labor, low birth weight, and amniotic fluid infection in case of pregnancy
• Persistent symptoms like itching, burning, and discomfort
• Damage to vulvar and vaginal tissues from recurrent inflammation and irritation
• Mental health issues like anxiety, depression, and decreased sexual confidence
• Unnecessary antibiotic use due to misdiagnosis or incorrect treatment

Preventing Vaginitis

Keeping vaginitis (a common inflammation in the vagina) at bay and upkeeping vaginal health are heavily reliant on patients’ awareness and maintaining good hygiene practices. This includes regular cleaning of the genital area with gentle soap and water, wearing underwear made of breathable cotton materials, and steering clear of douching (washing or cleaning out the vagina with water or other mixtures of fluids).

Practicing safety during sexual activities is also crucial which means using condoms and getting regular screenings for sexually transmitted infections (STIs). Additionally, understanding how to correctly use antibiotics, avoiding items that may irritate the area such as scented feminine products, and adopting a healthy lifestyle contribute to reducing the risk of vaginitis.

It’s important that women are aware of the correct way to use the toilet and clean themselves afterwards to avoid repeated infections. Women should also remember that the practice of douching can increase the chances of getting vaginitis.

Recognizing the symptoms and risk factors, along with sticking to the treatment plans, can contribute to timely intervention and management of vaginitis. Providing learning material can give patients the information they need to actively take part in maintaining optimal vaginal health.

Given the expected global spread and economic effects of vaginitis in the future, it’s crucial for wealthier countries to enhance their quality of care for vaginitis sufferers. With more researchers focusing on human microbiota (the community of microorganisms living inside and on human bodies), probiotic treatments are receiving a lot of attention. As science continues to progress, we can expect more information regarding the composition of the vaginal microbiome (the community of microorganisms living in the vagina) and how it can help prevent and treat vaginitis.