Vaginal infections are frequent causes of distress and discomfort in adult women. The most common vaginal infections are bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis. Some vaginal infections are transmitted through sexual contact, but others such as candidiasis (yeast infections) are not.
Bacterial vaginosis (BV) is the most common cause of vaginitis symptoms among women of childbearing age. BV – previously called nonspecific vaginitis or Gardnerella-associated vaginitis – can be transmitted through sexual activity, although the organisms responsible have also been found in young women who are not sexually active. BV is due to a change in the balance among different types of bacteria in the vagina. Instead of the normal predominance of Lactobacillus bacteria, increased numbers of organisms such as Gardnerella vaginalis, Bacteroides, Mobiluncus, and Mycoplasma hominis are found in the vagina in women with BV. Investigators are studying the role that each of these microbes may play in causing BV. The role of sexual activity in the development of BV is not understood; intrauterine devices (IUDs) may increase the risk of acquiring bacterial vaginosis.
Trichomoniasis, sometimes referred to as "trich", is a common STD that affects 2 to 3 million Americans yearly. It is caused by a single-celled protozoan parasite called Trichomonas vaginalis. Trichomoniasis is primarily an infection of the urogenital tract; the urethra is the most common site of infection in men, and the vagina is the most common site of infection in women.
Vulvovaginal candidiasis (VVC), sometimes referred to as candidal vaginitis, monilial infection, or vaginal yeast infection, is a common cause of vaginal irritation. It has been estimated that approximately 75% of all women will experience at least one episode of VVC during their lifetime. VVC is caused by an overabundance or overgrowth of yeast cells (primarily Candida albicans) that normally colonize in the vagina. Several factors are associated with increased rates of VVC in women, including pregnancy, uncontrolled diabetes mellitus, and the use of oral contraceptives or antibiotics. Other factors that may increase the incidence of VVC include the use of douches, perfumed feminine hygiene sprays, topical antimicrobial agents, and tight, poorly ventilated clothing and underwear. There is no direct evidence that VVC is transmitted by sexual intercourse.
Other Causes of Vaginitis
Although most vaginal infections in women are due to bacterial vaginosis, trichomoniasis or vulvovaginal candidiasis, it is clear that there are other possible causes. These causes may include allergic and irritative factors or other STDs. Noninfectious allergic symptoms can be caused by spermicides, vaginal hygiene products, detergents or fabric softeners. Cervical infections are also often associated with abnormal vaginal discharge, but these infections can be distinguished from true vaginal infections by appropriate tests. Finally, in uninfected women, vaginal discharge may be present during ovulation and may become so heavy that it raises concern.
Gardnerella, formerly Haemophilus, is an anaerobic bacteria that is a main contributor to bacterial vaginosis. It is sometimes sexually-transmitted, but can stick around for years as a passive part of the vaginal flora, only to flare up. It seems to occur in up to a quarter of relatively monogamous women and in half of women with multiple male partners. As bacterial vaginosis, Gardnerella is one of the three main causes of vaginal discharges, along with Trichomonas and Candida albicans. Antibiotic therapy for male partners seems of only marginal value, and the distinguishing characteristic of the infection is nearly no Lactobacillus vaginal presence, the main part of the flora that retains the lactic acid and peroxide balance so important in a healthy vagina. Live culture yogurt, as both food and douches help the problem.
Risk Factors for vulvovaginal candidiasis:
The primary symptom of bacterial vaginosis is an abnormal vaginal discharge with a fishy odor, which is especially noticeable after intercourse. However, nearly half the women with clinical signs of BV report no symptoms. A physician observes these signs during a physical examination and from various tests of vaginal fluid.
Trichomoniasis, like many other STDs, often occurs without any symptoms. When symptoms occur, they usually appear within 4 to 20 days of exposure, although symptoms can appear years after infection. The symptoms in women include a heavy, yellow-green or gray vaginal discharge, discomfort during intercourse, vaginal odor, and painful urination, or no symptoms at all. Irritation and itching of the female genital area, and on rare occasions, lower abdominal pain also can be present. The symptoms in men include a thin, whitish discharge from the penis and painful or difficult urination. However, most men do not experience any symptoms.
The most frequent symptoms of vulvovaginal candidiasis in women are itching, burning, and irritation of the vagina. Painful urination and/or intercourse are common. Abnormal vaginal discharge is not always present and may be minimal. The discharge is typically described as cottage-cheese-like in nature, although it may vary from watery to thick in consistency. Most male partners of women with VVC do not experience any symptoms of the infection. However, a transient rash and burning sensation of the penis have been reported after intercourse if condoms were not used. These symptoms are usually self-limiting.
The cause of vaginitis cannot be adequately determined solely on the basis of symptoms or a physical examination. Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis.
A sample of vaginal fluid can be examined under a microscope to detect the presence of the organisms associated with bacterial vaginosis. Diagnosis is based on the presence of numerous "clue cells" (vaginal lining cells that are coated with G. vaginalis and other BV organisms), a fishy odor, and decreased acidity of vaginal fluid.
Trichomoniasis is usually diagnosed in women by examining vaginal fluid under the microscope for evidence of the parasite; in some cases it can be detected on a Pap smear. Because only small numbers of parasites may be present during infection in a male, microscopic examination of discharge from the penis often does not reveal the presence of parasites. However, a sample of fluid from the penis may be taken from which the parasite can be grown in culture in the laboratory. Cultures may be required to establish the diagnosis in women who have no symptoms but are at high risk of infection. Cultures can also confirm the diagnosis in symptomatic women whose microscopic examinations are negative.
Because few specific signs and symptoms are usually present, vulvovaginal candidiasis cannot be diagnosed by the patient's history and physical examination. VVC is usually diagnosed through microscopic examination of vaginal secretions for evidence of yeast forms.
All women with bacterial vaginosis should be informed of their diagnosis, including the possibility of sexual transmission, and offered treatment. Generally, male sex partners are not treated. However, in cases of BV that do not respond to drug therapy, treatment of male partners may be helpful. Many women with symptoms of BV do not seek medical treatment, and many women who do not display symptoms decline treatment. Until the long-term consequences of untreated BV are known, routine treatment of all asymptomatic carriers is not necessary.
Acidophilus, "friendly" bacteria, can be reintroduced into the body both systemically, through oral acidophilus, and locally, through the douche. Vaginitis may also be produced by bowel bacteria, such as Escherichia coli, migrating into the vagina. Normally, the vagina's mucosal lining provides immunological protection against such bacterial infiltration, but if this lining is deficient, an infection may develop. A deficiency may be caused by poor health, aggressive intercourse, declining hormone levels, poor diet, or abnormal microflora populations. Several forms of vaginal douching for four consecutive nights are appropriate here.
Although symptoms of trichomoniasis in men may disappear within a few weeks without treatment, men can transmit the disease to their sex partners even when symptoms are not present. Therefore, it is preferable to treat both partners to eliminate the parasite.
Condoms and diaphragms may be helpful in preventing the spread of trichomoniasis. Although there is some laboratory evidence that spermicides can kill STD organisms, scientists are still evaluating the usefulness of spermicides in preventing STDs. Some studies have found that frequent use of spermicides (more than three times a week) may cause vaginal inflammation.
Women who have chronic or recurring vulvovaginal candidiasis may need to be treated for extended periods of time and oral antifungal drugs may be suggested. They should work with their physicians to determine possible underlying causes of their chronic yeast infections. Because there is no evidence for sexual transmission of VVC, routine treatment of male partners is unlikely to reduce recurrence.
A sufficient intake of probiotics or friendly bacteria can help keep yeast regrowth to a minimum. Other treatments include the application of a very weak vinegar douche or application of dilute tea tree oil solution. Since oral consumption of live acidophilus-cultured yogurt has been proven beneficial, acidophilus suppositories should have the same or a more rapid effect. If candida is suspected of being more than a local problem, more systemic anti-candidal treatments will need to be utilized.
Researchers are investigating the role of bacterial vaginosis in pelvic infections that result in infertility and tubal (ectopic) pregnancy. There is a growing body of evidence suggesting an increase in adverse outcomes of pregnancy such as premature and low-birth-weight infants among women with BV.
Although previously trichomoniasis was not thought to result in any important complications, recent studies have linked it to two serious consequences. Data now suggest that trichomoniasis may increase the risk of transmission of human immunodeficiency virus (HIV), the virus that causes AIDS, and may cause delivery of low-birth-weight or premature infants. Additional research is needed to fully explore these relationships.
Bacterial vaginosis results from an overgrowth of normal bacteria in the vagina. It produces no symptoms in about 85% of cases, but some women may experience an unpleasant fishy odor with vaginal discharge.
Scientists are finding that the status of vaginal flora may significantly affect both the amount and the survival of HIV virus inside the female genital tract. Abnormal vaginal flora – i.e. infection with candida or bacterial vaginosis – corresponded with increased amounts of HIV virus in the cervico-vaginal secretions of women who were HIV-positive. The HIV infection rate among women with bacterial vaginosis is twice as high as it is in those with healthy vaginal flora. Understanding these dynamics can "help shape preventative strategies aimed at reducing both heterosexual and the mother-to-child transmission of HIV", the researchers observed. [BJOG 2001;108: pp.634-641]
Yeast infections are more common among women with increased levels of estrogen. This is seen in those who use estrogen-containing birth control pills and among women who are pregnant. The increased hormone level causes changes in the vaginal environment that make it a media for fungal growth and nourishment.
A decrease in estrogen results in several vaginal changes. The vaginal lining becomes thinner and more fragile resulting in an increased risk of bacterial infection.
Citrus seed extract is useful for vaginal candida infections. In a study done by the Universidad Autonoma de Nuevo Leon in Mexico, 20 women douched using grapefruit seed extract every 12 hours for 3 consecutive days. 15 patients were cured after the first treatment. Four patients received treatment twice to become symptom free and receive negative laboratory results and 1 patient repeated the treatment 3 times until the lab report came back negative.
Daily vaginal douches with a 0.4% solution of tea tree oil in one quart of water was found to be an effective treatment for trichomonas when continued for several days in a row. This percentage can be approximated by adding 1 teaspoon of tea tree oil to 2 cups of water.
In one study of 100 women with chronic yeast vaginitis who had failed to respond to various over-the-counter or prescription anti-fungal medicines, 98% successfully treated their infections with boric acid capsules over a period of 2-4 weeks. [Antifungal agents vs. boric acid for treating chronic mycotic vulvovaginitis. J Reprod Med 1977;36: pp.593-7]
The best cure for vaginal yeast infections (yeast vaginitis) is cheap, safe and more effective than the over-the-counter or prescribed drugs. Simply insert boric acid capsules into your vagina twice per day for 5-14 days (although it may be cured after just a single day). Discontinue if you get a bloody discharge.
Carefully fill up size zero (single 'ought' or "0") empty gel caps (or veggie caps, available at a health food store, for those who don't want to use gelatin products) with boric acid, using the tip of a knife. Insert deeply into your vagina. You may want to wear a pad as it tends to be runny. It can also be helpful to take some of the loose powder and spread it on the labia. Make sure to lift the clitoral hood, where the infection seems to stagnate for some reason. Make sure you do this only after cleansing all areas thoroughly, including under the clitoral hood. This helps to relieve external itching.
If recurrent yeast infections have been a problem, they can be prevented by using one capsule of boric acid vaginally at bedtime twice per week, beginning one week after menstruation. The use of a panty liner is recommended.
Dilute boric acid can also be used in the form of a vaginal douche.
*** WARNING ***
Boric acid is toxic if taken internally, but safe when used vaginally.
Twice-daily vaginal douches, using 2 teaspoons full of acidophilus/bifidus powder in a quart of warm water, will help treat many recurrent vaginal yeast infections. Even just taking probiotics orally will increase the colonization of these organisms in the vagina and help prevent infections from occurring.
When unknown organisms may be contributing to chronic problems, a Uro-Genital Disease Panel (Swab or Urine) can test for the presence of Ureaplasma urealyticum, Mycoplasma genus screen, Herpes simplex viruses (HSV 1 and HSV 2 combined), Chlamydia trachomatis, Human papilloma virus – types 6/11, Human papilloma virus – types 16/18 and Cytomegalovirus (CMV).
Vaginal infections lead to a reduction in beneficial vaginal microflora. A study showed that the vaginas of 47 of 53 healthy women, but only 30 of 102 women with bacterial vaginosis, contained predominantly L. acidophilus and L. plantarum. Additionally it showed that 72% of the healthy women and 77% of those with vaginosis produced hydrogen peroxide for its bactericidal effect. Vaginal douching with 1⁄4 cup of 3% hydrogen peroxide mixed in 2 cups of water will reduce the population causing the infection. Vaginal implants of ozone gas will have this beneficial effect also.
Both of these therapies should be followed with some kind of microflora repopulation either orally or by implant.
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