Throw us a bone

by Nancy Sullivan, CNM, MS

Vaginal infection, also known as vaginitis or vaginosis, is one of the most frequent reasons that women seek care from their obstetrician-gynecologist¹. There are many causes of vaginitis, but the most common infections are bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC), or vaginal yeast/fungal infection. Both of these conditions are encouraged by changes in the normal acidity or the hormonal balance in the vagina. In the healthy state, lactobacilli (the "good bacteria") are present and release lactic acid to maintain a normal acidic vaginal environment. When lactobacilli are decreased or eliminated and the vagina becomes less acidic, the "bad bacteria" and yeast proliferate, much like weeds in a poorly-tended garden. Factors that increase the likelihood of these changes and resulting infection are pregnancy, diabetes mellitus, immunosuppressive disorders such as HIV, and use of antibiotics or steroid medications¹.

Symptoms of vaginitis include itching, irritation and burning on the vulva (inner and outer lips around the vagina) and in the vagina, including around the urethra. In addition, there may be an abnormal or malodorous vaginal discharge that is white or grey-green in color and watery or thick and cheesy in consistency. However, many women have no symptoms, and the condition is found on a routine exam or at an initial prenatal visit^1,2.

Although these conditions traditionally were thought to be minor and regarded primarily as a nuisance, recent epidemiologic studies have shown an association between bacterial vaginosis and serious medical and obstetric problems. These include increased susceptibility to sexually transmitted infections such as gonorrhea and chlamydia, trichomonas, HIV and herpes, urinary tract infections, and pelvic inflammatory disease (PID), an infection in the uterus or womb and/or fallopian tubes tubes that carry eggs from the ovaries to the uterus^1,3. PID, in turn, can increase the risk of tubal pregnancy, a dangerous condition in which the egg implants and starts to grow in the tube or other location outside the uterus; and of infertility. In pregnant women, BV can increase the risk of premature birth or low birth weight. There is evidence that screening and treatment in pregnant women before twenty weeks reduces preterm birth and preterm low-birthweight babies⁴.

Since many women tend to diagnose and treat themselves with over-the-counter (OTC) medications, frequently incorrectly, vaginitis, particularly bacterial vaginosis, has become a significant health concern. In one study of symptomatic women about to purchase an OTC product for yeast infection, only about a third actually had pure VVC. It is likely that many of the remaining two-thirds had BV, a more common and serious infection⁵.

Correct diagnosis of vaginal infections generally requires a visit to a women's healthcare provider. The clinician will obtain a history of the current and previous episodes, symptoms, and any attempts at self-treatment. The examination should include inspection of the vulva and vagina, vaginal pH and "whiff" testing (release of a "fishy" odor when an alkaline substance such as potassium hydroxide is added to the discharge) for fishy or amine odor, which is characteristic of BV. The exam should also include microscopic examination of the vaginal secretions to look for clue cells, seen with BV, or yeast buds and spores, seen with VVC. Frequently, the findings on examination and subsequent microscopic testing are not consistent with the description of symptoms offered by the patient and result in a change of diagnosis and appropriate treatment¹.

Vulvovaginal Candidiasis

Although women may have an asymptomatic yeast infection, most patients complain of vulvar or vaginal itching, burning, or soreness, painful intercourse, or burning with urination as urine passes the inflamed urethral tissues. On visual inspection of the external genitalia, the tissue may appear very red, dry, cracked, and shiny¹. The vaginal discharge may be white, thick, and have a "cheese curd" consistency. It is generally non-malodorous. The vaginal pH is usually normal. If the exam and tests are negative despite patient symptoms consistent with yeast, a culture should be obtained and sent to the lab¹.

Ninety percent of yeast infections in women are classified as uncomplicated (infrequent, mild to moderate symptoms, suspected C. albicans organism, and in normal, non-pregnant woman)¹. These women can be treated with any of several OTC vaginal creams or suppositories used for three to seven days, prescription single-dose vaginal creams, or single-dose oral fluconazole, a prescription drug. Fluconazole is contraindicated during pregnancy².

Boric acid capsules can be an effective and inexpensive treatment for yeast infections that are unresponsive to the usual antifungal medications, may be helpful with recurrent or resistant cases, and do not require a prescription⁶. To make them, purchase the USP boric acid powder and #00 gelatin capsules at the pharmacy. Fill the capsules with the powder and insert one capsule in the vagina twice a day for two to four weeks⁷. Boric acid changes the pH of the vagina, making it less hospitable to yeast organisms, those pesky "weeds" in the garden. Recent research has shown limited support for probiotics and lactobacilli as a treatment for VVC^8,9,10. These are found in some food products such as yoghurt and juice, and in pill form in pharmacies and health stores.

Complicated cases of VVC (recurring more than four times a year, severe symptoms or findings, non-albicans candida infection, or an abnormal host (diabetes or other severe medical illness, immunosuppression, other vulvovaginal conditions, or pregnancy)² require more aggressive and longer treatment, which should always be under the supervision of a medical professional¹.

Bacterial Vaginosis

Bacterial vaginosis is the most common vaginal infection in women of childbearing age; it is common in pregnant women¹⁰. Like VVC, it results when the natural balance of bacteria in the vagina is disturbed, the pH is changed, the "good" bacteria such as lactobacilli disappear, and the "bad" bacteria proliferate¹⁰. These include Gardnerella vaginalis and some anaerobic (not requiring oxygen) organisms. In fact, BV was formerly referred to as Gardnerella infection. As the microbiology of BV is better understood, it has become evident that it is a polymicrobial infection with a wide variety of other organisms that may play a role. Little is known about risk factors, but a new sexual partner or multiple partners may increase the risk; although BV is not considered to be a sexually transmitted infection¹. In lesbian women, partners of women with BV are more likely to have the infections themselves¹. Douching may kill the normal vaginal bacteria and set up an environment receptive to BV organisms.

BV is difficult to diagnose by symptoms or vaginal examination alone, since many women have no symptoms and the only common finding on exam is an abnormal watery, malodorous discharge. BV is diagnosed by finding three out of four of Amsel's criteria - abnormal discharge, vaginal pH greater than 4.5, positive amine or "whiff" test and more than 20% of vaginal epithelial cells being clue cells³. Clue cells are easy to find on microscopic exam; they have a stippled appearance from the bacteria clinging to their surface and they tend to clump together. If the diagnosis is still uncertain, a gram stain of the vaginal discharge can be done for a Nugent's score, which counts the number of normal lactobacilli (gram-positive rods) and abnormal species (gram-negative or gram-variable rods)^1,10.

Bacterial vaginosis is treated with antibiotics, usually either clindamycin or metronidazole. These drugs work equally well according to research trials. Metronidazole is cheaper and doesn't kill off the lactobacilli, but clindamycin has fewer side effects such as metallic taste, nausea and vomiting¹. Metronidazole in combination with oral or vaginal lactobacillus is more effective than metronidazole alone³. Several other antibiotics may be effective, but more research is needed to demonstrate that. Oral or intravaginal lactobacillus capsules alone were an effective treatment in one clinical study³. Ineffective treatments include triple sulfa cream and hydrogen peroxide douche, which can also be harmful³. After treatment, reinfection or relapse is common, with up to 30% of women becoming positive again on testing within three months of treatment, and almost 70% after a year. In recent research, probiotics with lactic acid bacteria strains such as lactobacillus show promise in treating BV as well as preventing re-infection; and they have few side effects unlike metronidazole and other antibiotics^8,9,10,11. However, the current evidence is not sufficient to recommend for or against probiotics, and more research is needed⁹. As understanding of the microbiology and pathogenesis of BV advances, improved treatments should become available¹².

Summary

VVC and BV are common infections in women, and they are frequently not taken seriously by women themselves or by their care providers. Misdiagnosis occurs in up to a third of cases, leading to incorrect treatment. BV is associated with an increased risk of serious genital infections in women, especially during childbearing years and during pregnancy, and with increased risk of HIV-1 transmission. Understanding of these serious complications has put an increased emphasis on the importance of diagnosing and treating vaginal infections correctly.

References

1. Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infectious Disease Clinics of North America. 2008;22:4.
2. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention, MMWR Recomm Rep. 2006;4:55(RR-11):54.
3. Oduyebo OO, Anorlu RI, Ogunsola FT. The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women [Review]. Cochrane Database of Systematic Reviews. 2009;(3):CD006055.
4. Sangkomkamhang US, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery [Review]. Cochrane Database of Systematic Reviews. 2009;(1).
5. Ferris DG, Nyirjesy P, Sobel JD et al. Over-the-counter anti-fungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis. Obstetrics and Gynecology. 2002;99:419-25.
6. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: Use of topical boric acid and flucytosine. American Journal of Obstetrics and Gynecology. 2003;189(5):1297-1300.
7. University of Washington School of Medicine. Available at: http://uwmedicine.washington.edu/Patient-Care/Our-Services/Medical-Services/Gynecology/Pages/ArticleView.aspx?subId=391. Accessed on November 2, 2010.
8. Abad CL, Safdar N. The role of lactobacillus probiotics in the treatment or prevention of urogenital infections - a systematic review. Journal of Chemotherapy. 2009;21(3):243-52.
9. Senok AC, Verstraelen H, Temmerman M, Botta GA. Probiotics for the treatment of bacterial vaginosis. [Review]. Cochrane Database of systematic Reviews. 2009;(4):CD006289.
10. Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. [Review]. Expert Reviews in Antiinfective Therapy. 2009;7(9)::1109-24.
11. Ya W, Reifer C, Miller LE. Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double blind, randomized, placebo-controlled study. American Journal of Obstetrics & Gynecology. 2010;203:120,e1-6.
12. Hay P. Recurrent bacterial vaginosis [Review]. Current Opinion in Infectious Diseases. 2009;22(1):82-6.

This article has been reviewed by a member of the Wellness Partners Editorial Board.

Posted November 2010