Vaginal discharge can be harmless or deserving of therapy. Experts explain how to make the correct diagnosis and determine appropriate treatment.
Most women find changes in vaginal discharge distressing. Too often women attribute symptomatic discharge (e.g., one that is off-color, has a foul odor, and causes burning or itching) to a yeast infection, which they attempt to self-treat with an OTC remedy. In most cases, however, the problem is not a yeast infection but bacterial vaginosis (BV). And only a health-care provider can make the diagnosis and determine what treatment is necessary.
Even a change in discharge quantity may be distressing. Women taking oral contraceptives often report an increase in discharge. But this is normal since hormones cause a thickening of the cervical mucus, which impedes the progress of sperm.
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Setting the stage for vaginitisThe purpose of normal physiologic vaginal discharge is to lubricate the vagina.
The vagina contains lactobacilli, which act as vaginal regulators and maintain a healthy acidic environment. Interference with these organisms, either by unnecessary applications of such products as vaginal deodorants and OTC antifungals or by douching, can alter normal functioning and leave women susceptible to vaginitis.
Vaginitis can often be attributable to contact dermatitis, which causes inflammation and does not have an actual infectious component. Determine what household or hygiene products patients are using and whether they have made any recent changes. Such products include anything that can come into contact with the vulva. Encourage patients to keep a diary of their symptoms and the products they use. Condoms, soaps, face wash that may drip during showering, shampoos, laundry detergent, and toilet paper can all be irritating to the vulva. Type of underwear (in terms of fabric and style) and, most importantly, the brand of feminine pads used should be considered too, since symptoms that are worse after menses may be related to the pads. Make special note of symptoms that are worse during work hours; patients often forget that the products they use at work may be different than those they use at home.
Of course, vaginitis can also be caused by bacteria and yeast. The causative agent must be identified by a medical provider. Medication used in the absence of true infection can destroy the necessary lactobacilli, in turn reducing the body’s natural ability to ward off bacteria.
Sorting out the symptoms
Symptoms can be truly diagnostic, or they can create confusion. Yeast (i.e., Candida) infections are often associated with white curdlike discharge, burning, and redness of the vulval tissue. Depending on the extent of the infection, there may be a significant amount of swelling as well. The discharge typically does not have a foul odor. Without proper treatment, the tissue can become damaged, slowing the healing process. Long-term insults to the vulval and vaginal tissue (recurrent infections or infections that continue due to improper treatment) can result in irreparable damage. This can lead to a condition known as vulvodynia. Intercourse can assist yeast organisms to enter and inhabit vulval tissue. If this is allowed to occur, patients may go on to have pain with intercourse; some patients have pain with just sitting or standing.
Diagnosing vulvodynia is quite difficult, and the condition is frequently missed. Patients with suspected cases should be referred to a specialist. Practitioners without proper training may recommend treatments that can further damage and destroy the tissue. Overtreatment of the vagina is as harmful as undertreatment.
The usual symptoms of BV are yellow or green vaginal discharge, burning, and a fishy odor. However, some symptoms are vague and need to be evaluated by a clinician. Intercourse tends to exacerbate symptoms; BV is not a sexually transmitted infection but rather a sexually associated infection. Symptoms are worsened by alterations in vaginal pH (normal 3.8-4.5), which can occur with the introduction of semen, menstrual blood, or douching.
The need for prompt evaluation
Patients require quick access to a clinician. Anyone who has had a vaginal infection knows that the symptoms interrupt day-to-day life, and concentration at work or home can be impossible. Offering a woman the next available appointment two or more weeks later is going to cause her to seek relief with an OTC medication even if her discomfort is not due to yeast. We have witnessed non-clinician staff treating patients over the phone based on the same vague symptoms, often multiple times. Although these treatments may cure some patients, for others they will only compound the problem. The importance of evaluation cannot be stressed emphatically enough. Patients who are misdiagnosed continue to suffer, become frustrated, lose faith in you, and take longer to cure.
Laboratory or in-office testing
Various laboratories have different sample collection methods using different devices. If you do not use the correct collection media, your sample may die in transit. Please contact your local lab for the correct media to collect and transport your specimen.
You may also do your own in-office testing. Preparing a wet mount slide has become a lost art in most practices. Time constraints placed on each visit may make it seem impossible to prepare a wet mount for each patient who has a vaginal complaint. If you have the right materials and microscope, however, the procedure can be quick and productive.
The technique for collecting vaginal discharge for wet mounts currently used in our practice surpasses all other methods we have tried. This technique is cost-effective, requires few materials, and can result in immediate diagnosis and treatment (see “Diagnosing vaginitis—the role of pH paper, the whiff test, and microscopy”). This eliminates the use of an unnecessary or wrong medication and the need to call the patient back days later when the diagnosis is reported from the lab.
Possible results and the diagnosis they signify are presented in Table 1.
Treatment
Once you’ve established the diagnosis, the best source of updated treatment information is the CDC (www.cdc.gov/std/treatment/2006/vaginal-discharge. Accessed April 2, 2008). Treatment regimens are generally different for pregnant and non-pregnant patients.
Bacterial vaginosis. All non-pregnant patients with symptomatic BV require treatment to relieve symptoms and prevent post-abortion or post-hysterectomy complications (Table 2). Suggested medications include topical and oral metronidazole or topical clindamycin. Symptomatic pregnant patients should be treated to prevent adverse pregnancy outcomes (Table 3). Clinicians who screen asymptomatic patients should do so at the first prenatal visit and start any needed therapy immediately. Only systemic metronidazole or clindamycin is recommended; no topical agents are included in the treatment regimen for pregnant patients. Treatment of sex partners does not appear to affect pregnancy outcomes and is not recommended.
Vulvovaginal candidiasis (VVC). Treatment of uncomplicated VVC in nonpregnant patients centers around topical azoles; fluconazole is the only oral agent recommended (Table 4).Intravaginal preparations of some topical azoles are available OTC. Patients whose symptoms are unrelieved by OTC products or who suffer a recurrence within two months of discontinuing treatment should be evaluated by a clinician. Sex partners do not require treatment unless the woman suffers recurrent bouts. Frequent recurrences are generally treated with azoles as well, but for a longer duration. Only topical azoles are recommended during pregnancy.
Summary
If a patient complains of vaginal symptoms, do the appropriate testing, i.e., cultures, microscopy, etc.; don’t treat over the phone; and prescribe the most appropriate medication while taking into consideration the patient’s status of compliance. For example, a seven-day vaginal treatment is not the best option for patients with a history of noncompliance.
