Vaginal Infection Treatment

Three infections, three different treatments

In a healthy vagina, Lactobacillus (the helpful bacteria that protect the vagina) are in the majority and keep the environment acidic. When this balance is upset, or when a germ enters from outside, vaginitis (inflammation of the vagina) develops. The three most common causes are:

• Bacterial vaginosis: not an infection caught from someone, but an upset in the balance of bacteria in the vagina. It is the most common cause of discharge in women of reproductive age.
• Vaginal thrush (candidiasis): an overgrowth of yeast in the vagina when its natural balance is upset. About 75% of women have it at least once in their lives.
• Trichomoniasis: a sexually transmitted infection caused by a single-celled parasite (Trichomonas vaginalis).

Each of the three needs a different medicine. A medicine that helps one does not work for the others, so the right diagnosis is needed before treatment.

Bacterial vaginosis

Cause and transmission

The protective Lactobacillus bacteria decrease and are replaced by an overgrowth of anaerobic bacteria (bacteria that grow without oxygen) such as Gardnerella. It is not considered a classic sexually transmitted infection; it can also occur in women who have never had sex. Even so, sexual activity, a new partner or more than one partner, and unprotected sex increase the risk.

Symptoms

• Thin, watery, grey-white or yellowish discharge that coats the vaginal wall in a thin layer.
• A fishy smell, which becomes stronger after sex and during a period.
• Marked itching, redness or swelling is usually absent or very mild.

Diagnosis

The diagnosis is usually made at the examination. It is enough to find at least three of the Amsel criteria (four simple examination findings):

1. Grey-white discharge of the same consistency throughout.
2. A vaginal pH (level of acidity) above 4.5.
3. A fishy smell that becomes stronger when a special drop is added to the discharge (smell test).
4. "Clue cells" (vaginal cells whose surface is covered with bacteria) seen under the microscope.

Nugent scoring (grading the types of bacteria on a stained slide) in the laboratory is a more precise method. A culture for Gardnerella, on the other hand, is not recommended for diagnosis; because this culture is not specific to bacterial vaginosis (it can also be positive in other situations), it is misleading.

Treatment

• The active substances used are metronidazole or clindamycin; in some cases tinidazole or secnidazole from the same group may be preferred.
• Treatment can be given by mouth (tablets) or vaginally (cream or gel). The doctor decides which is suitable according to pregnancy status and previous treatments.
• Partner treatment is not recommended. Studies have shown that treating the male partner does not reduce recurrence in the woman.

Vaginal thrush (candidiasis)

Cause and transmission

In 85–90% of cases the yeast responsible is Candida albicans; less often other species such as Candida glabrata are found. Vaginal thrush is not a sexually transmitted infection; it appears when the natural balance of the vagina is upset.

Symptoms

• White, thick discharge that looks like cottage cheese or curds.
• There is usually no smell, or a slight yeasty smell.
• Severe itching and burning are to the fore; redness and swelling of the outer genital area, pain during sex, and burning when urine touches the outer area.

Diagnosis

In a yeast infection the vaginal pH is normal (below 4.5); this is one of the clues that separates it from the other two. A sample of the discharge is examined under the microscope and yeast cells are seen. If symptoms continue but nothing is found under the microscope, or if the infection keeps coming back, a yeast culture (growing the yeast in the laboratory) is done; the culture helps to identify the species responsible.

Treatment

• For uncomplicated thrush, the azole group (a group of antifungal medicines) is used: either fluconazole taken by mouth, or pessaries and creams placed in the vagina (such as clotrimazole or miconazole).
• Partner treatment is not routinely recommended. Only if the male partner has symptoms of balanitis (redness and itching of the head of the penis) is a local antifungal cream recommended for him too.

Trichomoniasis

Cause and transmission

The cause is Trichomonas vaginalis, a single-celled parasite with whip-like tails. Trichomoniasis is definitely a sexually transmitted infection.

Symptoms

• Plentiful, frothy, yellow-green discharge.
• An unpleasant smell, itching and irritation of the outer genital area, pain during sex, burning when passing urine.
• At the examination, spots of pinpoint bleeding on the cervix (the neck of the womb) may be seen (a "strawberry cervix").

Diagnosis

The vaginal pH is high (usually between 5 and 7). Moving parasites may be seen under the microscope, but this method picks up only 50–70% of infections. The method preferred in current guidelines is molecular testing (tests that look for the genetic trace of the germ); it is 3–5 times more sensitive than the microscope.

Treatment

• Treatment is with medicines from the nitroimidazole group (a group of antibiotics that work against parasites and some bacteria) taken by mouth: metronidazole or tinidazole.
• Vaginal metronidazole gel is not adequate for trichomoniasis and is not used for this purpose.
• Partner treatment is essential. The sexual partner or partners must be treated at the same time, even if they have no symptoms. Sex should be avoided until the treatment has been completed and the symptoms have gone.

The three infections compared

The table shows the general features. Symptoms are not always this typical; the definite distinction is made by examination and tests.

At the practice in Muratpaşa, Antalya, vaginal infections are diagnosed and treated.

If the infection comes back

• Bacterial vaginosis: after treatment it can come back within 3 months in about 30% of women. When it keeps recurring, a suppressive treatment lasting several months, with vaginal gel applied at set intervals, or a switch to a different group of antibiotics may be planned.
• Vaginal thrush: it is considered "recurrent" when there are 4 or more episodes a year. The infection is first brought under control, then a maintenance (continuing) treatment lasting several months is given. In resistant cases that do not respond to fluconazole or are caused by less common species, vaginal boric acid capsules may be recommended. A culture is important in this situation.
• Trichomoniasis: first, whether the partner has taken the treatment and the possibility of being infected again are looked into. If needed, a longer course of treatment by mouth is given; if resistance to the medicine is suspected, a drug sensitivity test is recommended.

Vaginal infections in pregnancy

In pregnancy some medicines are not used, and for others the way they are given changes. For this reason, medicines should not be self-prescribed when symptoms appear in pregnancy.

• Bacterial vaginosis: it is linked to a risk of premature birth, the waters breaking early and inflammation of the lining of the womb after birth. Routine screening is not recommended in low-risk pregnant women without symptoms. In pregnant women with symptoms, metronidazole or clindamycin by mouth or vaginally can be used; according to the guidelines, metronidazole has been shown not to cause developmental abnormalities in the baby at any stage of pregnancy.
• Vaginal thrush: it is more common in pregnancy because of the rise in the hormone oestrogen. In pregnancy antifungal medicines taken by mouth are avoided; only vaginal creams and pessaries are preferred, as a longer course of treatment.
• Trichomoniasis: it is linked to a risk of premature birth and low birth weight. In pregnant women with symptoms, metronidazole by mouth is used; tinidazole is not preferred because the data on its safety in pregnancy are insufficient.

For care during pregnancy, see Pregnancy Care.

Prevention: what do the guidelines recommend?

• Do not douche. The vagina is an organ that cleans itself. Washing the inside with water or cleansers upsets the protective bacteria and the acidity, and increases the risk of both bacterial vaginosis and thrush. The ACOG, CDC and BASHH guidelines recommend avoiding vaginal douching.
• Avoid perfumed soaps, shower gels, genital sprays and scented pads. For the outer genital area, lukewarm water or a gentle soap-free cleanser is enough.
• Choose cotton, breathable underwear; tight, synthetic clothing creates a warm, damp environment that makes it easier for yeast and bacteria to grow.
• Probiotics: the use of oral or vaginal probiotics containing Lactobacillus to support treatment or to prevent recurrence is being studied. However, current guidelines do not yet have enough evidence that they can replace antibiotic or antifungal treatment.
• In trichomoniasis, treating the partner at the same time and avoiding sex until treatment is finished are important in preventing reinfection.

The drawbacks of self-medication

Using the wrong cream or antibiotic:

• upsets the balance of the vagina even further,
• temporarily masks the symptoms and makes diagnosis harder,
• can lead to the development of resistant strains,
• delays the right treatment. In trichomoniasis, because the partner is not treated as well, the infection can be passed on again.

When should you see a doctor?

1. When you have vaginal discharge, itching or an unpleasant smell for the first time.
2. When over-the-counter medicines do not help, or when symptoms come back shortly after treatment.
3. When the discharge is accompanied by lower abdominal pain, fever, severe pain during sex or bleeding after sex.
4. In pregnancy or if pregnancy is suspected.

To learn which features of discharge are considered normal, see Vaginal Discharge.