Vaginal Discharge

Why is it natural to have some vaginal discharge – secretion?

Vaginal secretion is the body’s natural way to clean and defend the vagina against infection and to provide lubrication. It is normal for there to be a little white or yellowish discharge, which may leave a yellowish patch on underclothes. A woman in her reproductive years discharges about 2 grams of epithelial (surface) cells and about half a gram of mucus each day.

The volume of normal discharge will vary between women. Some may seem to have more than average and there may be no abnormality to account for it – this is called leukorrhoea. The epithelial cells are rich in glycogen, which is a carbohydrate. Lactobacilli are bacteria normally found in the vagina that are able to break down glycogen to lactic acid. The lactic acid keeps the fluid in the vagina slightly acidic and this protects against infections. Oestrogen tends to increase the amount of glycogen. Ultimately, the hormone environment alters the amount of normal vaginal discharge.

Around the time of ovulation (egg release), usually about 14 days before the next period, there is an increased amount of clear vaginal discharge. There is also an increased discharge when pregnant.

A number of factors will contribute to the volume of the normal discharge. These include the stage of the menstrual cycle, hormone medication (e.g. oral contraception or hormone replacement therapy increase vaginal discharge), sexual arousal and activity, and clothing. There is an increased fluid discharge around the time of ovulation (egg release); this occurs fourteen days before the next period is due. Pregnancy is associated with an increase in vaginal discharge.

Many women experience a brown discharge or a pink discharge before or after a period.

Related Medical Abstracts

  • The ecologically wrong vaginal Lactobacilli.

How can I tell if my vaginal discharge is abnormal?

Vaginal discharge is one of the more common reasons for a woman to consult her doctor. A troublesome increase in vaginal discharge may need assessment. An offensive odour, vaginal and vulval (external) irritation or soreness are common accompanying symptoms when there is infection.

A brownBlood stained discharge is always an indication for medical assessment. Bacteriological (swab) and blood tests are required particularly if there is any possibility of a sexually transmitted disease.

Vaginal douching

It is natural for women to be fastidious about their hygiene and many regard vaginal douching as part of female cleanliness. Historically douching was regarded as therapeutic, reducing the likelihood of infections in the pelvis, and some, inappropriately, assumed it had a role in contraception. Many chemists have sold perfumed solutions designed for the purpose.

frequent douching probably does more harm than good. The vagina is capable of keeping itself clean. The vaginal fluid is rich in protective bacteria (Q 22.1) and excessive douching may reduce their numbers significantly. Chemicals in the douching fluid and the nozzle or tube may cause trauma and irritation. Douching may increase rather than decrease vaginal discharge. It may be reasonable to undertake douching once each month after a period. Daily washing the vulva, perineum (Figure 2.2) and anal area, perhaps with the benefit of a bidet, can be recommended.

Related Medical Abstracts

  • Factors associated with vaginal douching in military women. (2006-01)
  • Vaginal douches and other feminine hygiene products: women’s practices and perceptions of product safety. (2006-02)
  • Vaginal douching practices of women in eight Florida panhandle counties. (2006-03)

 

What can cause abnormal vaginal discharge?

 

There are several reasons why an abnormal vaginal discharge may occur including:

  • Vaginal infections:
    • Candida (thrush).
    • Trichomonas vaginalis.
    • Bacterial vaginosis.
  • Cervicitis ( cervical erosion).
  • Cervical erosion / ectopy ( cervical erosion).
  • Cervical polyps (cervical polyps)
  • Foreign body such as a retained tampon. Occasionally a tampon may be inadvertently forgotten. If a tampon should be forgotten for a few days, a serious condition called ‘Toxic Shock Syndrome’ can develop. Children may explore themselves with various objects. In addition to vaginal discharge, a ‘foreign body’ left in the vagina is associated with some blood stained discharge.
  • Perfumed soaps.
  • Douching too frequently: this may result in excessive discharge.
  • Atrophic vaginitis. After the menopause the natural vaginal secretions diminish. The vaginal lining may become inflamed leading to discharge, which can be blood stained. Other reasons for such blood stained discharge must be excluded by your doctor before local oestrogen treatment (topical oestrogen) or HRT (HRT-hormone-replacement-therapy).
  • Blood stained discharge may occasionally be the presenting symptom of cervical cancer. (Q32.07).

What are the more common vaginal infections?

There are a number of microorganisms that may cause vaginal infection and several may co-exist.

  • Candida.

What is thrush? Thrush infection caused by yeast organisms that are found in the vagina in 25% of women usually without any symptoms. The most common species of candida to be found in the vagina is Candida albicans which is an organism that lives in the bowel and can easily be transferred from back to front passage. Candida symptoms occur when there is a yeast infection. High blood sugar levels (diabetes mellitus), pregnancy, antibiotics and steroid administration tend to increase the incidence of candidiasis. An acidic environment encourages the growth of the candida.

Typically, the candida symptoms include vaginitis (inflammation of the vagina) which is accompanied by intense irritation. There is often a thick white discharge (described as milk curds). The skin of the vulva surrounding the vaginal entrance may be acutely red – vulvitis.

  • Trichomonas vaginalis.

This is a protozoan (each organism is much bigger than a bacterium and is capable of propelling itself by means of a flagella which is hair-like structure). Infection is generally acquired by sexual contact. There is an offensive,  frothy green discharge and often vaginal and vulval soreness and irritation.

Related Medical Abstracts

  • Gynaecological and microbiological findings in women attending for a general health check-up (1998-01)

What is bacterial vaginosis?

Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women during their reproductive years; it is more common than “thrush”. There is a fishy. smelly discharge, which is intensified after intercourse and during menstruation. Itching and soreness are not features of BV. In 1983 the condition was called bacterial vaginitis but inflammation of the vagina is not a feature and it was renamed vaginosis. There have been other names including non specific vaginitis, haemophilus vaginitis and non specific vaginosis.

A variety of microorganisms have been implicated but we still do not know which are the main culprits. Attention has focused on a bacterium named Gardnerella vaginalis. This organism can be found in more than 50% of healthy women. A thousand-fold increase in concentration of Gardnerella and other anaerobes (bacteria that can thrive at low oxygen levels) is typical of BV. Some suggest that BV is a sexually transmitted condition. Bacterial vaginosis, however, can occur in virgins. Diagnosis is made essentially from the history and the nature of the discharge, which has a typical pattern on direct microscopic examination. Swabs sent for culture are not helpful.

Bacterial vaginosis is likely to occur when the balance between protective organisms (lactobacilli) and potential pathogens (organisms associated with disease) is adversely altered. Excessive vaginal douching, for example, may lead to bacterial vaginosis by removing the lactobacilli. Semen reduces the natural acidity of the vagina and predisposes to BV.

There have been suggestions that BV may be a factor in miscarriage and premature delivery and studies are under way to investigate the potential benefit of antibiotic treatment. The author has introduced the hypothesis that sub-clinical bacteria ascending into the uterus (bacteria endometrialis) may provide a plausible explanation for a variety of gynaecological and obstetric enigmas including unexplained infertility, recurrent miscarriage, excessive vaginal bleeding, and blood pressure problems in pregnancy (pre-eclampsia). A great deal of research will be required to investigate this concept as these conditions probably result from a variety of causes, which will confound analysis. At this time we do not know whether antibiotics will prove to be of value but research has begun.

 

Related Medical Abstracts

  • Prevalence of bacterial vaginosis: 2001-2004 national health and nutrition examination survey data. (2007-01)
  • Clinical diagnosis of bacterial vaginosis. (2006-01)
  • Prevalence of bacterial vaginosis in a community setting and role of the pap smear in its detection. (2005-01)
  • Bacterial vaginosis, ethnicity, and the use of genital cleaning agents: A case control study (1999)
  • Bacterial vaginosis: An update. (1998)
  • Recurrent bacterial vaginosis. (1998)
  • Sex, thrush and bacterial vaginosis. (1997)
  • Defining bacterial vaginosis: To BV or not to BV, that is the question. (1996)
  • Plasma cell endometritis in women with symptomatic bacterial vaginosis. (1995)
  • Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. (1995)
  • A longitudinal study of bacterial vaginosis during pregnancy. ( 1994)
  • Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. (1994)
  • Bacterial vaginosis is associated with prematurity and vaginal fluid mucinase and sialidase: Results of a controlled trial of topical clindamycin cream. (1994)
  • Observations concerning the microbial etiology of acute salpingitis. (1994)
  • Bacterial vaginosis. (1992)
  • Treatment of bacterial vaginosis with lactobacilli. (1992)
  • Is bacterial vaginosis a sexually transmitted disease? (1991)
  • Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. (1991)
  • Reservoir of four organisms associated with bacterial vaginosis suggests lack of sexual transmission. (1990)
  • Treatment of bacterial vaginosis in women with vaginal bleeding complications of discharge and harboring Mobiluncus. (1990)
  • Diagnosis of bacterial vaginosis by direct gram stain of vaginal fluid. (1983)
  • Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. (1983)

 

How is the cause of vaginal discharge determined?

 

The diagnosis is determined from the story, examination findings and investigations that usually include sampling the discharge (swab tests) and obtaining a laboratory report. How are vaginal infections treated?

From a theoretical point of view, one should usually await the results of investigations before commencing treatment. In clinical practice one is keen to make an early start in assisting patients and it is common practice to commence treatment on the basis of clinical observations and

Adjust treatment subsequently according to investigation results.

Candida may respond to Nystatin (Nystan BMS) vaginal pessaries and cream. The full course of 14 days should be followed. Candida is sensitive to imidazole derivatives (Table 22.1), which are usually applied locally as creams or pessaries.

Table 22.1  Imidazoles used for the treatment of genital candida infections.

 

Imidazole Derivative Preparation Manufacturer
Clotrimazole Canesten Bayer
Clotrimazole Masnoderm Dominion
Econazole Ecostatin BMS
Econazole Gyno-Pevaryl Janssen-Cilag
Fenticonazole Lomexin Dominion
Isoconazole Travogyn Schering
Miconazole Gynodaktarin Janssen-Cilag

Canesten cream and Canesten Pessary - Clotrimazone

Canesten cream and pessary for the treatement of vulvo-vaginal thrush.

The vaginal creams may be applied internally for vaginal infections and externally for vulval infections. The creams may also be applied to the penis of the partner particularly when there are recurrent infections. There are four pessaries designed for single application. These are Canesten-1, Ecostatin-1, Gynokatarin-1 and Gyno-Pevaryl 1.

Three preparations are taken orally fluconazole (Diflucan 150 Pfizer), ketoconazole (Nizoral- Janssen-Cilag) and itraconazole (Sporanox- Janssen-Cilag).

The vaginal creams may be applied internally for vaginal infections and externally for vulval infections. The creams may also be applied to the penis of the partner particularly when there are recurrent infections. There are four pessaries designed for single application. These are Canesten-1, Ecostatin-1, Gynokatarin-1 and Gyno-Pevaryl 1. Three preparations are taken orally fluconazole (Diflucan 150 Pfizer), ketoconazole (Nizoral- Janssen-Cilag) and itraconazole (Sporanox- Janssen-Cilag).

 

Related Medical Abstracts

  • Itraconazole vs fluconazole for the treatment of uncomplicated acute vaginal and vulvovaginal candida in nonpregnant women: a metaanalysis of randomized controlled trials.(2008-01)

How is vaginal trichomonas treated?

Trichomonas vaginalis is sensitive to metronidazole (Flagyl Hawgreen). The male partner may be symptom free but will act as a source for re-infection if he does not receive treatment as well.

Recurrent vaginal thrush (vaginal candida). How can this be prevented?

Swab tests should be taken to confirm that you really are having bouts of thrush. Whilst most people have heard of thrush, relatively few know about bacterial vaginosis and this is more common than thrush.

About one per cent of women will have more than six episodes of vaginal candida a year. It is prudent to exclude underlying illness and to correct other causes of vaginal discharge such as cervical ectropion (erosion cervical erosion).

Preventative measures include avoiding clothes that keep the genital area moist. Natural fibres such as cotton are preferable to nylon. Underclothes should be thoroughly rinsed. Daily bathing/showering may be helpful but frequent vaginal douching should be avoided as this may remove protective organisms. Irritant soaps and bubble baths should be avoided. Shampoos should not be used in the bath. Use a soft clean towel and dab rather than rub. Rough flannels should not be used.

One of the orally active agents may eliminate the reservoir of candida in the bowel although this may subsequently recur. Wiping the anal area from front to back may help to prevent transfer of candida to the vagina; soft toilet paper should be used. The objective is to prevent recurrence. As antibiotics may be associated with acute episodes, those particularly at risk should re quest treatment for candida at the same time. The male partner should be offered local or oral treatment. Some women will require regular preventative treatment usually administered after each period.

 

Related Medical Abstracts

How is bacterial vaginosis treated?

Bacterial vaginosis (Q 22.7) responds to antibiotics active against anaerobic bacteria. Oral metronidazole?(Flagyl – Hawgreen) tablets two or three times daily have been the traditional first line of treatment. Clindamycin (Dalacin – Pharmacia and Upjohn) vaginal cream introduced each night for a week and metronidazole gel (Zidoval – 3M Health Care) one application for five nights have provided further options. Some women are prone to recurrence; there is no evidence that treating the partner provides benefit.

Related Medical Abstracts

 

Does the combined oral contraceptive pill cause vaginal thrush (vaginal candida)?

 

The pill can probably be associated with, at most, a small increase in the incidence of candida.

Related Medical Abstracts

 

What is the toxic shock syndrome?

 

This condition was first described in 1978. The majority of cases happen in women during their periods and there is a link with the use of tampons particularly if they are accidentally retained for too long. The illness is characterised by fever and shock (drop in blood pressure). The early cases were associated with almost 10% mortality but with modern therapy this rate has fallen to less than 3%.

 

Support Groups

 

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others’ experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

 

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.
Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women’s health sites may help you (internet information). The following are more specialised relevant Web sites:-

Bacterial vaginosis:

Candida (thrush):

  • Www.fda.gov/fdac/features/396-yst.html
  • Familydoctor.org/handouts/206.html
  • Www. Msu.edu/user/eisthen/yeast/

Vaginal discharge:

Lichen Planus:

  • http://familydoctor.org/600.xml
  • http://www.nlm.nih.gov/medlineplus/National Vaginitis AssociationPO Box 33275St. PaulMN 55133-3275

    USA

    The Patient Support Trust

    White Hart Stables

    Bank Street

    Bishops Waltham

    Southampton

    Hampshire SO32 1AN.