Vaginal Discharge

How does the vagina protect itself?

A healthy vagina contains helpful bacteria called Lactobacillus. These bacteria break down the sugar in the cells (glycogen) to produce lactic acid and keep the environment acidic (pH 3.8–4.2). This acidity is a natural shield that prevents disease-causing microbes from multiplying.

When this balance is disturbed — by antibiotic use, vaginal douching, hormonal changes or a microbe entering from outside — inflammation of the vagina (vaginitis) develops.

What is normal discharge like?

• Amount: usually small.
• Appearance: clear or white, and may be lumpy; it does not stick to the walls of the vagina but collects lower down.
• Smell: there is none.
• Accompanying complaints: itching, burning, irritation or soreness on passing urine are not seen.

In the middle of the menstrual cycle (at ovulation) the discharge may increase temporarily because of the rise in oestrogen, and take on a more watery, stretchy consistency — this is entirely normal.

The three most common infections

Bacterial vaginosis

• Appearance: increased, thin, watery, grey-white; it coats the walls of the vagina in a thin layer.
• Smell: typical — fishy. It becomes more noticeable after intercourse and during the period.
• The distinguishing point: because there is no true inflammation, marked redness, swelling or severe itching are generally not seen.

Thrush (fungal infection)

• Appearance: thick, white, in clumps like cottage cheese; it forms plaques (raised patches) firmly stuck to the walls.
• Smell: there is none — a fishy smell is definitely absent.
• The distinguishing point: severe itching is in the foreground. It is accompanied by burning, irritation, swelling and redness of the external area, burning that increases when urine touches the external area, and pain during intercourse (dyspareunia).

Trichomoniasis

• Appearance: markedly increased, watery, profuse and frothy; yellow-green or greyish in colour.
• Smell: unpleasant.
• The distinguishing point: intense itching and burning, burning on passing urine, pain during intercourse and sometimes spotting after intercourse. On examination the surface of the vagina is red and swollen; in about 10% of cases pinpoint areas of bleeding are seen on the cervix.
• This is a sexually transmitted infection — that is the most important way in which it differs from the other two.

Why you should not diagnose yourself

What is done at the examination is simple and quick: the appearance of the discharge is assessed, the acidity (pH) is measured, a smell test is done and a sample is examined under the microscope. These few steps are enough to tell the three conditions apart.

• In bacterial vaginosis the diagnosis is made by assessing certain criteria together. Bacterial culture has no place in this diagnosis — because the bacterium held responsible can be found in the normal flora of 50–60% of healthy women as well.
• In thrush examination under the microscope is sufficient. If there are complaints but no findings under the microscope, or if it recurs more than four times a year, a culture should be done to determine which species is responsible.
• In trichomoniasis the detection power of the microscope is limited (51–70%). For this reason the most sensitive method is molecular testing, whose accuracy is above 95%.

A difference to know about in treatment: treating the partner

Treatment is planned entirely according to the organism and is carried out on prescription. But on the question of the partner, the three conditions differ:

• Bacterial vaginosis: it has been shown that treating the male partner does not reduce recurrence — treating the partner is not recommended.
• Thrush: treating the partner is not routinely recommended.
• Trichomoniasis: treating the partner is essential. Because it is transmitted sexually, partners need to be treated at the same time, whether or not they have symptoms. Sexual contact should be avoided until the treatment is finished and the complaints have settled.

In trichomoniasis, local treatment (cream or gel) is not recommended; because the active substance cannot reach the necessary areas adequately, the failure rate is high.

When should you seek help without delay?

If any of the following applies, do not lose time with medicines bought at the pharmacy:

1. Pregnancy. Bacterial vaginosis and trichomoniasis during pregnancy can lead to the waters breaking early, to premature birth and to low birth weight.
2. Fever, shivering and severe pain in the lower abdomen. The infection may have spread to the womb and the tubes; this is the warning sign of a condition that carries a risk of infertility.
3. Bloody, pink or brown discharge, or spotting after intercourse — the cervix needs to be assessed.
4. Any discharge starting after menopause. It must be investigated.
5. No response to a medicine bought without prescription: if the complaint has not eased within 3 days, or if it recurs immediately after treatment, a resistant species may be involved.