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Exactly how frequent vaginitis is among women is unknown. However, physicians and health plans know that it leads to 10 million office visits throughout the U.S. per year as one of the most common reasons for a woman to seek the advice of a physician.

Before I deal with the various forms of vaginitis I would like to review the causes of vaginal infections. Normally, there is an intricate balance between the bacteria that normally live in the vaginal flora and the main bacteria called Lactobacilli, which make up the majority of 70% of the bacterial flora producing the chemical milieu in the vagina. The milieu is slightly acidy (pH of around 4.0) and there is hydrogen peroxide released constantly in small amounts from theLactobacilli as well. This double effect limits the growth of other bacteria and the vaginal wall is accustomed to this milieu. The other 30 % of bacteria normally present in the vaginal secretion of a woman are the following (in descending order):

Gardnerella vaginalisUreaplasma urealyticum, Mycoplasma hominis, Bacteroides species, group B beta hemolytic streptococci, anaerobic Gram-positive rods, Gram-negative aerobes and a few others. (Ref.15, p. 400). Apart from bacteria, there are also yeast organisms, called Candida albicans, that are a normal part of the vaginal secretions. They are normally there, are non invasive as they are kept at bay by the acidy milieu and hydrogen peroxide released from theLactobacilli (Ref.15, p. 400 and Ref. 23, p.2657).

The interesting fact is that most of the pathogens in clinical vaginitis in humans are already there in the normal vaginal flora. The difference between normal and abnormal lies in the balance of the flora, the pH, the bacterial count and whether or not the vaginal wall gets inflamed.

The cause of bacterial vaginosis, which is one of the common forms of vaginitis, is a tremendous overpopulation of the vaginal flora where the total pathogen count per Gram of vaginal secretion has skyrocketed from the normal 10,000 count to 100 billions, a 7 log difference. No wonder that the woman affected by this has symptoms! (Ref.15, p. 400).

Symptoms of vaginitis

Although it is not possible to diagnose what kind of vaginitis a patient has, based on symptoms alone, there are fairly specific symptoms that are associated with certain bacteria, but not others.

The final diagnosis in case of a lack of clinical response has to wait till one or more cultures have been taken and were examined in a laboratory. This can serve the clinician as an additional guidance as to what specific treatment to order.

General symptoms for all of the vaginitis cases are abnormal vaginal discharge, vaginal burning, vaginal itchiness and pain with sexual intercourse (called “dyspareunia”).

Here is a table with the most common pathogens that cause vaginitis and the most common features.

Common types of vaginitis (symptoms, diagnostic tests, treatment)

Type of vaginosis: Symptoms: Diagnostic tests: Treatment:
bacterial vaginosis copious green, malodorous discharge, less itching pH › 4.5; clue cells and decreased lactobacilli metronidazol (Flagyl) or clindamycin
fungal vaginitis white cottage cheese-like discharge, itching and burning on slide: KOH preparation shows fungi; culture methods confirmCandida albicans butaconazole (Femstat), clotrimazole (Canesten) or oral fluconazole
trichomoniasis very painful and swollen,discharge with pus trichomonads that move, as well as clue cells metronidazole (Flagyl) orally
atrophic vaginitis atrophic vaginal mucosa is inflamed on inspection FSH and LH high in blood (menopause) estrogen vaginal cream or oral tablets

Some of the vaginitis cases are chronic or chronically recurring. For instance, with Candida albicans, commonly known as yeast vaginitis, the hormone changes with from taking the birth control pill or the changed hormone milieu with pregnancy can cause fairly sudden flare-ups of yeast vaginitis that tend to be more chronic recurrent. In cases where the immune system is weakened, such as in AIDS patients or other immune suppressed patients, a referral to a gynecologist for ongoing management of Candida vaginitis may be needed.

Diagnostic tests

Some of the diagnostic tests are listed in the table above. However, there are many possible underlying bugs that may be the main culprit. The diagnosis is based on a combination of clinical findings on examination, the history from the patient and possible cultures that may or may not be taken.

Treatment of vaginitis

Although the table above gives some indication how various types of vaginitis are being treated, there are many details that are beyond the scope of this text.

For instance, there are often initial treatment protocols and there are secondary treatment regimens that the physician might use (Ref.15, p. 402), if “plan A” does not work. In the case of a yeast vaginitis the patient may have tried some over-the-counter nystatin cream or nystatin tablets. The physician may next use butaconazole in a cream, if the initial therapy failed. After some swabs to see that no other pathogens were present, the physician may subsequently follow this by a course of fluconazole (150 mg tablets, once per day) for one or several weeks. At the same time there terconazole could be added as a cream intravaginally. However, the gynecologist has some other methods available as a tool such as the “triple dye” treatment, which occasionally is used and directly applied during a gynecological examination. At the same time efforts are perhaps directed at rebalancing the vaginal flora by life style changes. A lesser known fact is that smoking disbalances the vaginal flora among other negative health impacts and this adds another reason why you need to quit smoking, if you do so now. Add to this a low sugar diet and low starch diet (Ref. 2) including yoghurt in your food intake (Lactobacillus source) and you are well on your way to a recovery from chronic recurrent vaginal yeast infections.



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Last modified: November 12, 2014

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.