Vaginitis and Vaginosis

Anything that disrupts the balance of normal flora and/or that irritates the tissues of the vagina or vulva can potentially cause vaginitis.

The most frequent causes of vaginitis/vaginosis (up to 90%) are infections due to:

• Bacterial vaginosis, caused by a complex change in vaginal flora with a decrease in the number of normal lactobacilli and an increase in other bacteria, including Gardnerella vaginalis and Mycoplasma hominis.
• Candida albicans (yeast) infection, also called candidiasis, and sometimes caused by other Candida species
• Trichomonas vaginalis infection, also called trichomoniasis or "Trich," is a sexually transmitted parasitic infection.

Some other causes of vaginitis include:

• Allergic and irritant reactions to feminine hygiene products, use of petroleum jelly products within the vagina, bubble baths, tight underclothing (especially those made with synthetic fabrics that hold in moisture), perfumes, deodorant soaps, use of fabric softener sheets, latex condoms, etc.
• Thinning of the skin in the vagina and a loss of lubrication that is due to decreased estrogen; this is called atrophic vaginitis and is primarily seen in women during and after menopause.
• Hormonal imbalances
• Rarely, a foreign body in the vagina (such as a small piece of toilet tissue in a child or a forgotten tampon in a menstruating woman); this can irritate and cause an infection.

Bacterial vaginosis can increase a woman's risk of genital infections, specifically sexually transmitted diseases (STDs). STDs other than a trichomonas infection that can sometimes cause vaginitis and/or vaginosis include:

• Chlamydia
• Herpes 
• HPV (Human Papillomavirus)
• Gonorrhea
• HIV

Vaginitis and vaginosis may occur at any age but are most common in women of child-bearing age who are sexually active. However, it is important to note that vaginitis can also occur in women or girls who are not sexually active. A woman may have more than one cause of vaginitis/vaginosis at a time.

Risk factors for vaginitis/vaginosis include:

• Antibiotic use (can cause a loss of "good" bacteria in the vagina)
• Pregnancy (causes hormonal changes that may lead to irritation of the vagina)
• Frequent douching (can cause irritation and/or loss of normal flora)
• Sexual activity, multiple sex partners and/or a new sex partner
• Intrauterine device (IUD) use
• Use of oral contraceptives
• Underlying diseases, such as poorly controlled diabetes, skin diseases (dermatitis), and other conditions that affect the immune system
• Poor hygiene, especially when using the toilet
• Smoking
• Physical or emotional stress

The signs and symptoms associated with vaginitis and vaginosis may be vague and non-specific, involving general itching, pain, burning, redness, and swelling of the vagina. Depending on the cause, some distinctive signs and symptoms may be present and include one or more of the following:

• Bacterial infection (vaginosis)—a vaginal discharge that is thin, grey, or milky with an unpleasant fishy smell (due to chemicals called amines that increase the pH in the vagina) that is especially noticeable after sexual intercourse. There may or may not be vaginal itching and irritation. Most (85%) women with bacterial vaginosis have no symptoms.
• Yeast infection (candidiasis)—a vaginal discharge that can be thick and white like cottage cheese, along with itching, burning, burning with urination, redness and swelling, and painful sexual intercourse.
• Infection caused by Trichomonas (trichomoniasis)—a yellowish-greenish vaginal discharge that may be "frothy" and unpleasant smelling, itching, redness, painful sexual intercourse, and painful urination. Small red sores may be visible on the walls of the vagina or cervix during a pelvic exam. However, many women with trichomoniasis have no noticeable symptoms.
• Atrophic vaginitis—this condition, occurring in some women entering or in menopause, is defined as a thinning of the walls of the vagina. The women affected may have vaginal dryness, itching, and/or burning, pain during sexual intercourse, and a small amount of bleeding after sexual intercourse.

Rarely, the causes of vaginitis or vaginosis may lead to complications such as inflammation of the cervix or lining of the uterus or pelvic inflammatory disease (PID). In pregnant women, vaginosis can sometimes cause premature labor, preterm birth, low birth weight infants and, in some cases, can lead to the transmission of an infection from a mother to her newborn. Women who have a vitamin D deficiency and are pregnant may be more likely to get bacterial vaginosis. Bacterial vaginosis has also been associated with miscarriages in the second trimester of pregnancy.

Diagnosing vaginitis and vaginosis depends on your age and your risk factors for infection. The diagnostic process in a woman of child-bearing age begins with a physical exam, including a pelvic exam, and a medical history. Your healthcare practitioner will want to know about your symptoms, symptom duration and frequency, prescribed medications (such as antibiotics or oral contraceptives), and any over-the-counter treatments you may have tried. Your healthcare practitioner may ask about personal habits (douching, use of feminine products or scented soaps, tight clothing, etc.) and about sexual history. From this information, a decision may be made about what type of testing should be performed.

The goals with testing are to diagnose vaginitis or vaginosis and to determine the underlying cause in order to help guide treatment. Testing is also used to evaluate the best treatment options if you do not respond to initial therapy and/or if you have recurrent episodes.

Clinical diagnosis of bacterial vaginosis is based on the Amsel criteria, where three of the four following symptoms are present:

• Grayish-white vaginal discharge
• Vaginal pH greater than 4.5
• Presence of "clue" cells as determined by a wet prep (see below)
• Fishy odor present with the addition of 10% potassium hydroxide

Laboratory tests

A few testing methods may be performed in a medical office or clinic by the healthcare practitioner, or a sample may be collected and sent to a laboratory.

The "gold standard" for the diagnosis of bacterial vaginosis is the direct examination of the vaginal secretions, which can be viewed microscopically as an unstained wet mount or as a Gram stained slide.

Wet Prep (Wet Mount/Smear)
A drop of vaginal discharge is placed on a glass slide and then examined under the microscope. Examples of typical findings include:

• Bacterial vaginosis—the presence of "clue cells," which are cells from the lining of the vagina that are coated by bacteria. Additionally, the vaginal fluid will have few to no white blood cells (WBCs).
• Candida—yeast may be seen as budding yeast and/or tube or branch-like structures (pseudohyphae).
• Trichomonas—parasites that can be seen as oval bodies with hair-like structures (flagella) that move. An increased number of WBCs may also be seen.

Gram Stain
Vaginal fluid is placed on a glass slide and stained with a special dye (Gram stain). The slide is examined under a microscope for certain bacterial cell types and the evaluation is based on the quantity of each type of bacteria. If 20% or more of the cells from the vagina lining are covered by bacteria ("clue cells"), this is diagnostic for bacterial vaginitis. A decrease in the number of normal bacterial cells such as Lactobacillus species is associated with bacterial vaginosis. The presence of yeast cells can also be detected with a Gram stain, while the parasite Trichomonas is not detected by this method.

Other critical tests on the sample include the following:

pH Test
Vaginal discharge is checked for pH.

• A pH of less than 4.5 is normal but can also be seen with a yeast infection (candidiasis).
• An increased pH (such as greater than 5.0) may be seen with bacterial vaginosis and with trichomoniasis.

KOH Prep
A sample of the vaginal discharge is placed on a glass slide with a drop of 10% potassium hydroxide (KOH).

• Bacterial vaginosis: chemical compounds called amines will be released, causing a fishy odor.
• Candidiasis: yeast and pseudohyphae can often be seen more easily.
• Trichomoniasis: can also release an unpleasant odor.

Additional test methods are available for identifying the causes of vaginitis/vaginosis, such as:

• Molecular methods (e.g., nucleic acid amplification, NAAT) for identifying trichomonas, yeast or bacterial vaginosis.
• Rapid point-of-care tests for detecting trichomonas or bacterial vaginosis

Vaginal Cultures

• Bacterial vaginal cultures should be discouraged for the diagnosis of bacterial vaginitis. Gardnerella vaginalis can be cultured from 50-60% of healthy, asymptomatic women and therefore the growth of these bacteria in culture is difficult to interpret.
• Candidiasis: a fungal culture may be ordered to help guide treatment with persistent or recurrent infections and can be used to identify which yeast is present.
• Trichomoniasis:  a special trichomonas culture may be performed to detect trichomonads when microscopic exam is not sufficient.

Other Tests
If STDs are suspected, additional testing may be performed, such as:

• Herpes
• Chlamydia
• Gonorrhea
• Syphilis
• HPV
• HIV

If a woman has recurrent yeast infections, follow-up testing may be performed to look for underlying conditions that may be contributing to the vaginitis or vaginosis, such as diabetes.

Non-Laboratory Tests
Other than a physical examination, other non-laboratory tests, such as imaging, are usually not required for diagnosing vaginitis or vaginosis. However, if a serious complication such as pelvic inflammatory disease (PID) is suspected, then a pelvic or transvaginal ultrasound may be performed. This test may reveal the presence of enlarged fallopian tubes or an abscess.

It is not always possible to prevent vaginosis or vaginitis, but you can take steps to reduce the likelihood and reduce recurrence. These steps may include:

• Avoid douching and/or frequent baths
• Avoid feminine hygiene products, perfumed soaps, and other potential chemical irritants
• Avoid tight clothing and synthetic underclothes that may trap moisture
• Practice safe sex
• Practice (and teach children) good hygiene

There are several standard topical treatments (creams or suppositories placed inside the vagina) available for bacterial vaginosis and yeast infections, as well as oral treatments for bacterial vaginosis, candidiasis, and trichomoniasis. There are several different timing and dosing options available. Women should always follow the instructions provided.

For trichomoniasis and other sexually transmitted infections, treatment of a woman's sex partner is often recommended to increase the cure rate and help prevent re-infection. Trichomoniasis is usually self-limited in men, resolving within a couple of weeks.

If an uncomplicated yeast infection occurs again and the woman recognizes the symptoms, then over-the-counter treatment may be sufficient. However, if a woman's symptoms recur or persist, she should consult with her healthcare practitioner.