Vaginitis

Overview

Vaginitis refers to inflammation of the vagina that disrupts the normal balance of vaginal flora and can lead to a variety of uncomfortable symptoms. The vagina normally maintains a delicate ecosystem of beneficial bacteria and yeast, with a slightly acidic pH that helps prevent harmful microorganisms from overgrowing. When this balance is disrupted, inflammation and infection can occur, resulting in vaginitis.

There are several types of vaginitis, each with distinct causes and characteristics. The most common forms include bacterial vaginosis (BV), which accounts for approximately 40-50% of cases; vaginal yeast infections (candidiasis), comprising about 20-25% of cases; and trichomoniasis, a sexually transmitted infection responsible for 15-20% of cases. Other forms include atrophic vaginitis, which occurs due to decreased estrogen levels, and noninfectious vaginitis caused by allergic reactions or irritants.

The condition is extremely common, with studies suggesting that up to 75% of women will experience at least one episode of vaginitis in their lifetime. Certain factors increase susceptibility, including antibiotic use, hormonal fluctuations during pregnancy or menopause, diabetes, weakened immune system, and certain lifestyle factors. While vaginitis is not typically serious, untreated cases can lead to complications such as increased risk of sexually transmitted infections, pregnancy complications, and chronic discomfort that significantly impacts quality of life.

Symptoms

The symptoms of vaginitis can vary depending on the underlying cause, but typically involve changes in vaginal discharge, discomfort, and irritation. Understanding the specific symptom patterns can help healthcare providers determine the type of vaginitis and appropriate treatment.

Common General Symptoms

• Vaginal discharge - changes in color, consistency, amount, or odor
• Vaginal itching - ranging from mild to severe irritation
• Painful urination - burning sensation when passing urine
• Pain during intercourse - discomfort or pain during sexual activity
• Vaginal pain - soreness or discomfort in the vaginal area
• Vaginal redness - inflammation and redness of vaginal tissues

Symptoms by Type of Vaginitis

Bacterial Vaginosis Symptoms

• Thin, grayish-white vaginal discharge
• Strong, fishy odor, especially after intercourse
• Mild irritation or itching (less common)
• Increased discharge amount

Yeast Infection Symptoms

• Thick, white, cottage cheese-like discharge
• Intense itching and irritation
• Redness and swelling of the vulva
• Burning sensation during urination or intercourse
• Little to no odor

Trichomoniasis Symptoms

• Frothy, yellow-green discharge with strong odor
• Itching and irritation of the vagina and vulva
• Lower abdominal pain - mild discomfort in lower abdomen
• Discomfort during urination and intercourse
• Strawberry cervix (visible during examination)

Atrophic Vaginitis Symptoms

• Vaginal dryness and thinning
• Light bleeding after intercourse
• Shortening and tightening of the vaginal canal
• Watery vaginal discharge
• Urinary symptoms (frequency, urgency, UTIs)

Associated Symptoms

• Pelvic pain - discomfort in the pelvic region
• Suprapubic pain - pain above the pubic bone
• Sharp abdominal pain - acute pain in the abdomen
• Pain during pregnancy - pregnancy-related discomfort

Causes

Vaginitis can result from various factors that disrupt the normal vaginal environment. Understanding these causes is essential for proper treatment and prevention. The vagina normally maintains a balanced ecosystem, and any disruption to this balance can lead to inflammation and infection.

Infectious Causes

Bacterial Vaginosis (BV)

The most common cause of vaginitis, BV occurs when there's an overgrowth of naturally occurring vaginal bacteria:

• Disruption of normal lactobacilli (good bacteria)
• Overgrowth of anaerobic bacteria like Gardnerella vaginalis
• Not considered a sexually transmitted infection but more common in sexually active women
• Can occur in women who have never had sexual intercourse

Vaginal Yeast Infections

Caused by overgrowth of Candida species, usually Candida albicans:

• Disruption of normal vaginal flora allowing yeast overgrowth
• Common after antibiotic use
• More frequent in women with diabetes or weakened immune systems
• Can be triggered by hormonal changes

Trichomoniasis

• Caused by the parasite Trichomonas vaginalis
• Sexually transmitted infection
• Can survive on damp objects for short periods
• Often asymptomatic in men who can transmit it to partners

Non-Infectious Causes

Atrophic Vaginitis

• Decreased estrogen levels, especially after menopause
• Breastfeeding-related hormonal changes
• Surgical removal of ovaries
• Certain medications that affect estrogen levels

Irritant and Allergic Vaginitis

• Soaps, detergents, and fabric softeners
• Feminine hygiene products and douches
• Spermicides and latex condoms
• Synthetic underwear or tight-fitting clothing
• Perfumed toilet paper or sanitary products

Contributing Factors

• Antibiotic use: Disrupts normal vaginal bacteria
• Hormonal changes: Pregnancy, birth control pills, menstrual cycle
• Uncontrolled diabetes: High blood sugar promotes yeast growth
• Weakened immune system: HIV/AIDS, corticosteroid use
• Sexual activity: New or multiple partners, unprotected sex
• Hygiene practices: Excessive washing, douching

Risk Factors

Several factors can increase the likelihood of developing vaginitis. Understanding these risk factors can help in prevention and early intervention.

Behavioral Risk Factors

• Sexual activity:
  • Multiple sexual partners
  • New sexual partner
  • Unprotected sexual intercourse
  • Sexual activity at a young age
• Hygiene practices:
  • Douching (disrupts normal vaginal flora)
  • Using scented feminine products
  • Excessive washing of genital area
  • Wearing wet clothing for extended periods

Medical Risk Factors

• Antibiotic use: Broad-spectrum antibiotics kill beneficial bacteria
• Hormonal factors:
  • Pregnancy
  • Oral contraceptive use
  • Menopause
  • Hormone replacement therapy
• Medical conditions:
  • Diabetes (especially uncontrolled)
  • HIV/AIDS
  • Other immunocompromising conditions
  • Thyroid disorders

Lifestyle Risk Factors

• Clothing choices: Tight, synthetic underwear or pants
• Diet: High sugar intake may promote yeast growth
• Stress: Can weaken immune system
• Smoking: Associated with increased BV risk
• Hot tubs and swimming pools: Chlorinated water irritation

Age-Related Risk Factors

• Reproductive age: Highest risk during childbearing years
• Menopause: Increased risk of atrophic vaginitis
• Pregnancy: Hormonal changes increase susceptibility
• Puberty: Hormonal fluctuations

Diagnosis

Accurate diagnosis of vaginitis is essential for effective treatment. Healthcare providers use a combination of medical history, physical examination, and laboratory tests to determine the specific type and cause of vaginitis.

Medical History

Your healthcare provider will ask about:

• Current symptoms and their duration
• Characteristics of vaginal discharge
• Sexual history and practices
• Previous episodes of vaginitis
• Recent antibiotic use
• Contraceptive methods
• Hygiene products used
• Underlying medical conditions
• Current medications

Physical Examination

The examination typically includes:

• External examination: Inspection of vulva for redness, swelling, or lesions
• Speculum examination: Visual inspection of vaginal walls and cervix
• Bimanual examination: Checking for pelvic tenderness or masses
• Assessment of discharge: Color, consistency, amount, and odor

Laboratory Tests

Wet Mount Microscopy

• Immediate examination of vaginal discharge
• Can identify yeast cells, trichomonads, and clue cells
• Quick results available during office visit

pH Testing

• Normal vaginal pH: 3.8-4.5
• pH >4.5 suggests BV or trichomoniasis
• pH remains normal with yeast infections

Whiff Test (Amine Test)

• Adding potassium hydroxide to discharge sample
• Fishy odor indicates BV or trichomoniasis
• No odor with yeast infections

Additional Tests

• Vaginal cultures: For recurrent or resistant infections
• DNA probe tests: More sensitive for specific pathogens
• STI screening: For sexually active patients
• Gram stain: Detailed bacterial analysis

Diagnostic Criteria

Bacterial Vaginosis (Amsel Criteria - 3 of 4 required)

• Thin, homogeneous discharge
• pH >4.5
• Positive whiff test
• Clue cells on microscopy

Yeast Infection

• Yeast or pseudohyphae on wet mount
• Normal pH (3.8-4.5)
• Negative whiff test
• Typical cottage cheese-like discharge

Trichomoniasis

• Mobile trichomonads on wet mount
• pH >4.5
• Positive whiff test
• Frothy, yellow-green discharge

Treatment Options

Treatment for vaginitis depends on the underlying cause. Proper diagnosis is essential for effective treatment, as different types require different therapeutic approaches. Most cases respond well to appropriate treatment, though some may require longer therapy or lifestyle modifications.

Bacterial Vaginosis Treatment

First-Line Medications

• Metronidazole:
  • Oral: 500 mg twice daily for 7 days
  • Gel: 0.75% intravaginally once daily for 5 days
  • Avoid alcohol during treatment and 24 hours after
• Clindamycin:
  • Cream: 2% intravaginally at bedtime for 7 days
  • Oral: 300 mg twice daily for 7 days
  • May weaken latex condoms and diaphragms

Alternative Treatments

• Tinidazole: 2 g orally once daily for 2 days
• Secnidazole: 2 g oral granules in single dose
• Clindamycin ovules: 100 mg intravaginally at bedtime for 3 days

Yeast Infection Treatment

Over-the-Counter Options

• Miconazole: Cream or suppository for 1, 3, or 7 days
• Clotrimazole: Cream or tablets for 1, 3, or 7 days
• Tioconazole: 6.5% ointment single-dose
• Butoconazole: 2% cream for 3 days

Prescription Medications

• Fluconazole: 150 mg oral single dose
• Terconazole: Cream or suppository for 3 or 7 days
• Nystatin: 100,000 unit vaginal tablet for 14 days
• Ibrexafungerp: For recurrent infections

Trichomoniasis Treatment

• Metronidazole: 2 g orally in single dose (preferred)
• Alternative: Metronidazole 500 mg twice daily for 7 days
• Tinidazole: 2 g orally in single dose
• Important: Treat all sexual partners simultaneously
• Follow-up: Retest 3 months after treatment

Atrophic Vaginitis Treatment

Topical Estrogen

• Vaginal cream: Apply 2-3 times weekly
• Vaginal tablet: Insert twice weekly
• Vaginal ring: Replace every 3 months

Non-Hormonal Options

• Vaginal moisturizers: Regular use for comfort
• Lubricants: Water-based for sexual activity
• Ospemifene: Oral selective estrogen receptor modulator

General Treatment Measures

• Complete the full course: Even if symptoms improve
• Avoid irritants: During treatment period
• Sexual activity: May need to abstain during treatment
• Partner treatment: Required for STI-related vaginitis
• Follow-up: If symptoms persist or recur

Recurrent Vaginitis Management

• Extended therapy: Longer treatment courses
• Suppressive therapy: Preventive medication regimens
• Lifestyle modifications: Address risk factors
• Probiotic supplementation: May help restore vaginal flora
• Partner evaluation: For possible reinfection

Prevention

Preventing vaginitis involves maintaining healthy vaginal flora and avoiding factors that can disrupt the vaginal environment. While not all cases can be prevented, following these guidelines can significantly reduce the risk of developing vaginitis.

Hygiene Practices

• Avoid douching: Disrupts normal vaginal bacteria
• Gentle cleansing: Use mild, unscented soap on external areas only
• Wipe front to back: Prevents bacterial contamination
• Change tampons/pads regularly: Every 4-8 hours
• Avoid scented products: Feminine sprays, powders, and wipes

Clothing and Lifestyle

• Wear breathable cotton underwear
• Avoid tight-fitting pants and underwear
• Change out of wet swimsuits and workout clothes promptly
• Sleep without underwear to allow air circulation
• Wash new underwear before wearing

Sexual Health

• Use barrier protection with new or multiple partners
• Urinate after sexual intercourse
• Avoid petroleum-based lubricants with latex condoms
• Limit number of sexual partners
• Ensure partner treatment for STI-related vaginitis

Medical Considerations

• Take probiotics during antibiotic therapy
• Control blood sugar if diabetic
• Complete full course of vaginitis treatment
• Regular gynecological check-ups
• Discuss hormone therapy options if menopausal

When to See a Doctor

While mild vaginal symptoms may sometimes resolve on their own, certain situations require medical evaluation to ensure proper diagnosis and treatment. Seeking timely medical care can prevent complications and provide relief from uncomfortable symptoms.

Seek Immediate Medical Care If:

• Severe pelvic or abdominal pain
• High fever (over 101°F or 38.3°C)
• Heavy vaginal bleeding
• Symptoms during pregnancy
• Signs of severe infection (chills, vomiting)

Schedule an Appointment If:

• First-time vaginal symptoms
• Symptoms differ from previous infections
• Over-the-counter treatments haven't worked
• Symptoms persist after completing treatment
• Recurrent infections (more than 4 per year)
• New sexual partner or multiple partners
• Unusual discharge color or odor
• Symptoms interfere with daily activities
• Post-menopausal vaginal symptoms

Related Conditions

Several conditions may present with similar symptoms or occur alongside vaginitis:

• Urinary Tract Infection (UTI)
• Cervicitis
• Pelvic Inflammatory Disease
• Vulvodynia
• Lichen Sclerosus
• Contact Dermatitis

References

1. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(No. RR-4):1-187.
2. Sobel JD. Vaginitis. N Engl J Med. 1997;337(26):1896-1903.
3. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
4. Paavonen J, Brunham RC. Bacterial Vaginosis and Desquamative Inflammatory Vaginitis. N Engl J Med. 2018;379(23):2246-2254.
5. American College of Obstetricians and Gynecologists. Vaginitis in Nonpregnant Patients. ACOG Practice Bulletin No. 215. Obstet Gynecol. 2020;135(1):e1-e17.