Vulvovaginitis, vulvitis, and vaginitis are general terms that refer to the inflammation of the vagina and/or vulva (the external genital organs of a woman).These conditions can be caused by bacterial, fungal, or parasitic infections. Also, vulvovaginitis can be caused by low estrogen levels (called "atrophic vaginitis") or any type of allergic or irritation response from things such as spermicidal products, condoms, soaps, and bubble bath.
In general, vulvovaginitis causes vaginal discharge, irritation, and itching. One of the most common reasons why women visit their doctor is because of a change in vaginal discharge. It is completely normal for a woman to have a vaginal discharge, the amount and consistency of which varies during the course of the menstrual cycle. Each of the three most common types of vulvovaginitis will be described separately.
Bacterial vaginosis
Bacterial vaginosis is the most common cause of vaginitis during the childbearing years. Forty percent to 50% of vaginitis cases are caused by bacterial vaginosis. The occurrence of bacterial vaginosis is difficult to determine but studies have proposed that 10% to 41% of women have had it at least once. The occurrence of bacterial vaginosis in the United States is highest among African-American women and women who have had multiple sexual partners and lowest among Asian women and women with no history of sexual contact with men. Bacterial vaginosis is not considered a sexually transmitted disease although it can be acquired by sexual intercourse.
Bacterial vaginosis is not caused by a particular organism but is a change in the balance of normal vaginal bacteria. Ninety percent of the bacteria found in a healthy vagina belong to the Lactobacillus family. For unknown reasons, there is a shift in the bacterial population that results in overgrowth of other bacteria. Patients suffering from bacterial vaginosis have very high numbers of bacteria such as Gardnerella vaginalis, Mycoplasmahominis, Bacteroides species, and Mobiluncus species. These bacteria can be found at numbers 100 to 1000 times greater than found in the healthy vagina. In contrast, Lactobacillus bacteria are in very low numbers or completely absent from the vagina of women with bacterial vaginosis.
Candida vulvovaginitis
Candida vulvovaginitis also has been called "vulvovaginal candidiasis," "candidal vaginitis," "monilial infection," or "vaginal yeast infection." Twenty to 25% of the vaginitis cases are candida vulvovaginitis. It has been estimated that about 75% of all women get a vaginal yeast infection at least once. In 80-90% of the cases, candida vulvovaginitis is caused by an overgrowth of the yeast Candida albicans. The remaining cases are caused by other species of Candida. It is not known what causes the yeast overgrowth. However, antibiotics can inadvertently kill normal bacteria in the vagina and cause an overgrowth of Candida.
Candida vulvovaginitis is not considered a sexually transmitted disease because Candida species are commonly found in the healthy vagina. It is a rare disease in girls before puberty and celibate women. Vaginal yeast infections tend to occur more frequently in women who are pregnant, diabetic and not controlling their disease, taking birth control pills, or taking antibiotics. Some women have four or more attacks per year which is called "recurrent vaginal candidiasis."
Trichomoniasis
Trichomoniasis, which is sometimes called "trich," accounts for 15-20% of the cases of vaginitis. It is estimated that two million to three million American women get trichomoniasis each year. Unlike the previous two causes of vulvovaginitis, trichomoniasis is a sexually transmitted disease. This means that the disease is passed from person-to-person only by sexual contact. Trichomoniasis occurs in both men and women and is caused by an infection with the single-celled parasite Trichomonas vaginalis. Infection with Trichomonas vaginalis is frequently associated with other sexually transmitted diseases and assists the spread of the AIDS virus.
Causes and symptoms
Vulvovaginitis is most often caused by a bacterial, fungal, or parasitic infection as described above. Other microorganisms may cause vulvovaginitis, or it may be caused by allergic reaction, irritation, injury, low estrogen levels, and certain diseases. Risk factors for bacterial vaginosis include using an intrauterine device (IUD), non-white race, prior pregnancy, first sexual activity at an early age, having multiple sexual partners, and having a history of sexually transmitted diseases. Persons at an increased risk for candida vulvovaginitis include those who have had previous candida infections, frequent sexual intercourse, use birth control pills, have AIDS, are pregnant, are taking antibiotics or corticosteroids, are diabetic, use douches, use perfumed feminine hygiene sprays, wear tight clothing, or use vaginal sponges or an IUD.
The typical symptoms of vulvovaginitis are: vaginal discharge, itching, and irritation. Women may have few or no symptoms, while others may have pronounced symptoms. The main symptom of bacterial vaginosis is a fishy-smelling, thin, milky-white or gray vaginal discharge but itching and burning may also be present. The fishy smell is stronger after sexual intercourse. The symptoms of candida vulvovaginitis are itching, soreness, painful sexual intercourse, and a thick, curdy, white (like cottage cheese) vaginal discharge. Trichomoniasis symptoms are: painful urination, painful sexual intercourse, and a yellow-green to gray, foul smelling, sometimes frothy, vaginal discharge.
Diagnosis
Vulvovaginitis can be diagnosed and treated by a nurse practitioner or physician. Most insurance companies cover the costs of diagnosis and treatment. To diagnose vulvovaginitis, the doctor will examine the vagina (using a speculum to keep the vagina open) and take a sample of the vaginal discharge for tests and microscopic analysis. Laboratory culture results should be available in two to three days but the microscopic examination of the vaginal discharge may be immediately performed in the doctor's office. Diagnosis may be difficult because there are many different causes of vulvovaginitis. Women who think that they have vulvovaginitis should always visit their doctor to get an accurate diagnosis. Many women assume that they have a yeast infection and take over-the-counter medicines without first consulting their doctors.
There are four signs that indicate that a woman has bacterial vaginosis. These signs (called "Amsel's criteria") are: a thin, milky white discharge that clings to the walls of the vagina, presence of a fishy odor, a vaginal pH of greater than 4.5, and the presence of "clue cells" in the vagina. Clue cells are vaginal cells that are covered with small bacteria. A diagnosis of candida vulvovaginitis is made after finding a normal vaginal pH (4 to 4.5) and the presence of many yeast cells in the sample of vaginal discharge or growth of yeast on laboratory media. A trichomoniasis diagnosis is made when the parasites are found in the vaginal discharge either by microscopic examination or in laboratory cultures.
Treatment
Both bacterial vaginosis and trichomoniasis require prescription medication for treatment. Candida vulvovaginitis may be treated with either prescription or over-the-counter medicines. It is not advisable to take over-the-counter vaginal yeast infection medicines if one does not have a yeast infection. An Institute of Epidemiological Research survey of 390 gynecologists found that 44% of the women who were diagnosed with bacterial vaginosis had first treated themselves with over-the-counter yeast infection medications.
Bacterial vaginosis should be treated daily for one week with the antibioticsmetronidazole (Flagyl, Protostat) or clindamycin (Cleocin) either as pills taken orally or in a gel or cream form put into the vagina. Trichomoniasis is treated with either a large, single dose of metronidazole or with a smaller dose taken twice daily for one week. Male sexual partners of women with trichomoniasis also must be treated.
Candida vulvovaginitis is most often treated by the application of medicated gels, creams, or suppositories applied directly to the vagina. The antifungal drugs used to treat candida vulvovaginitis include oral fluconazole (Diflucan), butoconazole (Femstat), clotrimazole (Gynelotrimin, Mycelex), miconazole (Monistat), and ticonazole (Vagistat). Most require only one or a few days of therapy to be effective. Women who have recurrent candida infections may receive treatment for several weeks and then some form of a long-term preventative treatment.
Alternative treatment
One of the primary focuses of alternative treatment for vaginal conditions including vulvovaginitis is rebalancing the normal vaginal flora. To assist with this rebalancing, Lactobacillus acidophilus and L. bifidus are recommended, either taken internally or introduced directly into the vagina. Garlic (Allium sativum), both taken internally and inserted into the vagina (a peeled whole clove wrapped in gauze), may be helpful due to its antibacterial and antifungal actions. A variety of other herbs can be used as douches or in suppository form to help treat acute flare-ups of vaginal symptoms. For example a douche made by steeping 1–2 tsp. of calendula (Calendula officinalis) in boiling water (let the water cool before using) may help reduce inflammation. A boric acid douche can help to acidify the vaginal pH so that unwanted bacteria cannot survive and multiply. For atrophic vaginitis, especially in menopausal women, topical application of progesterone cream can help with the thinning of the tissue so that symptoms can abate.
Dietary modification and nutritional supplementation may also be helpful in the treatment of vulvovaginitis. Antioxidantvitamins, including A, C, and E, as well as B complex vitamins, and vitamin D, are recommended. Foods to avoid include cheese, alcohol, chocolate, soy sauce, sugar, vinegar, fruits, and any fermented foods. Wearing cotton underwear and loose fitting clothes and avoiding panty hose can help keep the vagina cool and dry, thus helping to prevent some forms of vulvovaginitis. Cases of chronic vulvovaginitis should be addressed on systemic level by an alternative practitioner.
Prognosis
Vulvovaginitis is a disease with minor symptoms and most women respond well to medications. It is believed that certain vaginal infections, if left untreated, can lead to more serious conditions such as pelvic inflammatory disease, endometritis, postsurgical infections, and spread of the AIDS virus.
Prevention
Vaginal infections may be prevented by following these suggestions:
Over-the-counter yeast infection treatments should not be taken unless the woman had been diagnosed with candidiasis before and recognizes the symptoms.
Douching should be avoided because it may disturb the balance of organisms in the vagina and may spread them higher into the reproductive system.
Thoroughly dry oneself after bathing and remove a wet bathing suit promptly.
Avoid wearing tight clothing and wear cotton underwear.
After a bowel movement, wipe from front to back to avoid spreading intestinal bacteria to the vagina.
PERIODICALS
Sobel, Jack D. "Vaginitis." The New England Journal of Medicine 337 (Dec. 1997): 1896-1903.
ORGANIZATIONS
National Vaginitis Association. 117 South Cook St., Suite 315, Barrington, IL 60010. (800) 909-8745. <VagAssoc@aol. com>. <http://www.vaginalinfections.org>.
