Vaginitis is the medical term for infection or inflammation of the vagina. It is a problem that is commonly encountered in the general gynaecologist’s clinic. In some cases, the vulva and cervix may be affected by infection and inflammation as well, giving rise to vulvitis and cervicitis respectively.
Common symptoms of vaginitis include vaginal discharge, itch and discomfort.
Some women may also experience dysuria (pain felt on urination), superficial dysparenunia (pain felt on penetration during sex) and spotting (typically after sex or outside of normal periods).
The most common causes of vaginitis are bacterial vaginosis, candida (yeast) infection and trichomonas infection. They account for 90 percent of cases. Less common but significant causes of vaginitis are infections caused by sexually-transmitted organisms such as chlamydia, gonorrhoea and herpes.
Not all cases of vaginal discharge are due to infection. Vaginal discharge can be normal (‘physiological discharge’). It can also be caused by presence of foreign objects in the vagina, allergic reactions, cervical conditions and rarely genital tract cancer. In postmenopausal women, vaginal discharge is commonly due to atrophic changes (‘atrophic vaginitis’).
Causes of vaginal discharge
| Infection / inflammation
|Non-sexually transmitted: bacterial vaginosis, candida
|Cervical conditions (e.g. polyp, ectropion*)
|Sexually transmitted: trichomonas, chlamydia, gonorrhea, herpes
||Foreign object (retained condom, forgotten tampon)
||Genital tract cancer
|| Allergic reactions
||Atrophic vaginitis (postmenopausal)
* Cervical ectropion is a condition in which the inner cervical cells are found on the outer part of the cervix.
The vaginal environment and physiological (‘normal’) vaginal discharge
The normal vaginal environment is a delicate ecosystem of ‘healthy’ bacteria and small amounts of candida (yeast). The normal pH of the vagina is usually acidic in nature. Lactobacillus is the main regulator of vaginal pH by making lactic acid. Maintaining the vaginal pH at an acidic level inhibits overgrowth of ‘healthy’ bacteria and yeast and prevents infections from bad bacteria and viruses.
Discharge flows from the vagina daily as the body’s way of maintaining a normal healthy environment. Normal physiological vaginal discharge consists of cervical and vaginal cells, bacteria, water, electrolytes and other chemicals. Normal discharge is usually clear or white, thick and mucouslike. There may be a slight odour. Vaginal discharge may become more noticeable near ovulation and in the week before the menstrual period.
The vaginal pH can change under the influence of various factors:
- Medical conditions which cause low immunity
- Hormonal changes (during the menstrual cycle, pregnancy, puberty, menopause)
- Birth control pills
- Intrauterine contraceptive devices
- Douching and other vaginal products
- Vaginal medications
- Foreign objects
Disturbance of the normal vaginal pH can alter the composition and balance of the vaginal ecosystem. This leads to overgrowth of ‘healthy’ organisms and infections from bad organisms, resulting in vaginitis.
How do I know if my vaginal discharge abnormal?
Although vaginal discharge can be physiological, it is advisable to seek medical advice under any of the following circumstances:
- Change in the nature of vaginal discharge – especially if it is foamy, greenish, foul-smelling or blood-stained;
- Other symptoms such as vaginal itch or discomfort, dysuria, dyspareunia, abnormal spotting, abnormal menstrual periods or abdominal pain;
- New sexual partner or more than one partner in the last year;
- Previous history of sexuallytransmitted disease or pelvic infection;
- Recent vaginal or caesarean birth or recent invasive gynaecological procedure e.g. abortion, insertion of an intrauterine device, in-vitro fertilisation etc.
What you can do to maintain a healthy vaginal environment – Do’s and Don’ts
|The vagina has a self-cleaning mechanism. Keep the genital area clean by washing daily with mild soap and water.
||Do not wash excessively or use a sponge to clean the genital area. Overcleaning can alter the vaginal pH, cause irritation and worsen vaginitis symptoms. Antibacterial or astringent soaps contain harsh chemicals which may irritate the vagina.
|If the genital area is irritated, aqueous cream can be kept in the fridge and dabbed on to cool and soothe the genital area as often as preferred. This
would reduce dryness and irritation.
|Avoid using the following on the genital area as these can contain irritants: bubble baths, hot baths
with scented products, douches, antiseptics, baby wipes, deodorants, some over-the-counter creams (e.g. tea tree oil, aloe vera).
|Wear loose-fitting breathable silk or cotton underwear and clothes.
||Avoid tight-fitting synthetic underwear (e.g. thongs, lycra) and clothes (e.g. tights, cycling shorts,
leggings, tight jeans).
|Wipe the genital area with soft white unscented toilet paper. Wipe from front to back to prevent faecal material from coming into contact with the vagina.
||Avoid coloured toilet paper as these contain dyes and other potentially irritating chemicals.
|Change tampons, sanitary pads and pantyliners regularly as exposure to soiled menstrual products for prolonged periods can increase the risk of infection.
||Do not wear sanitary pads or pantyliners on a daily basis.
|Seek treatment for incontinence as urine and frequent use of diapers cause genital irritation.
Bacterial vaginosis occurs when lactobacillus in the vagina is replaced by other bacteria. It is the
most common cause of vaginitis, accounting for 40-45 percent of cases and usually causes a ‘fishy’
thin off-white vaginal discharge, which is more noticeable after unprotected sex.
Although the majority of affected women are sexually active, bacterial vaginosis can occur in women who have never had sex. Other predisposing factors for bacterial vaginosis include oral sex, intrauterine
contraceptive devices, vaginal douching and pregnancy.
50 percent of bacterial vaginosis cases do not cause any symptoms and do not need treatment, unless the woman is undergoing gynaecological surgery or is pregnant and has previous preterm birth. Testing and treatment of male sexual partners is not needed and unhelpful in preventing repeat
|Treatment of bacterial vaginosis consists of a course of antibiotics and avoiding vaginal irritants.
Recommended antibiotics are metronidazole (flagyl) or clindamycin given through either the oral or
vaginal route. Avoid using alcohol during treatment with oral metronidazole and for 24 hours
thereafter. Metronidazole pills also interact with warfarin.
50 percent of affected women have a repeat episode of bacterial vaginosis within one year. In women who
have frequent episodes of bacterial vaginosis, these treatment strategies may be helpful:
• Change of intrauterine contraceptive device or switch to another form of contraception
• Regular use of condoms as semen raises the vaginal pH and disrupts the vaginal ecosystem
• Preventive treatment with antibiotics over 4-6 months.
|Candidiasis (‘yeast infection’)
Candidiasis occurs when there is an overgrowth of the yeast organism called candida, which is usually
found in small numbers in the normal vaginal environment. It is the second most common cause of
vaginitis, accounting for 20-25% of cases.
It usually causes a thick white odourless discharge. Vaginal itch and soreness are also prominent
symptoms. Predisposing factors for candidiasis include pregnancy, diabetes and medical conditions which cause low immunity, antibiotics and birth control pills.
20 percent of candidiasis cases do not cause any symptoms and do not need treatment. Testing and treatment of sexual partners is not needed because
candidiasis is not considered sexually transmitted.
|Treatment of candidiasis consists of a course of antifungal medications given by the oral or vaginal route.
Vaginal antifungal medications may weaken latex condoms so additional contraception is needed when the woman is using antifungals. 5 percent
of women have recurrent candidiasis (four or more repeat episodes of candidiasis in one year) and may
benefit from the following strategies:
• Good control of diabetes
• Switch from birth control pills to another form of contraception
• Preventive treatment with antifungal medications for six months.
Trichomonas is a sexuallytransmitted parasite with a high transmission rate of at least 70 percent after just one exposure to an infected partner. It is the third
most common cause of vaginitis, accounting for 15-20 percent of cases.
50-75 percent of infected persons have no symptoms. Common symptoms include foul-smelling yellow-green vaginal discharge and
|It is important to treat all cases of trichomonas infection, even if there are no symptoms.
Trichomonas infection can spread from the vagina
to the upper genital tract (i.e. the womb, tubes, ovaries), causing damage which can affect fertility and increase the risk of ectopic pregnancy.
Untreated trichomonas infection in pregnancy is associated with a high risk (30 percent) of preterm birth.
Testing and treatment of sexual partners is mandatory. Treatment consists of a course of oral antibiotics (metronidazole or tinidazole).
Atrophic vaginitis refers to a type of vaginitis that occurs because of oestrogen deficiency, usually after menopause. It occurs in up to 40 percent of postmenopausal women.
Oestrogen stimulates the growth of lactobacilli in the vagina. Lack of oestrogen causes thinning of the
vaginal skin and increases the pH of the vaginal environment. This predisposes the genital area to
|Because the problem is mainly due to lack of oestrogen, treatment of atrophic vaginitis usually depends on replacing oestrogen in the tissues.
Usually a cream, pessary or vaginal tablet or ring containing oestrogen is prescribed to replace oestrogen levels in the genital area. If there are other
menopausal symptoms that require treatment, oestrogen is delivered in a more generalised form via an oral tablet or skin patch.
Vaginal moisturisers and lubricants may also be given but these are usually not as effective as oestrogen. Antibiotics are not needed in the
treatment of atrophic vaginitis.