How can I know if I have a Vaginal Infection !?

One of the most common complaints for women is “vaginal infections”. Patients present to our clinics reporting symptoms of a presumed infection. Occasionally these symptoms truly coincide with an existing pathology, but in many other instances the reported symptoms stem from a background of healthy cyclic physiologic (normal) changes. 

A big number of women avoid visiting the doctor for such a complaint, and prefer heading directly to the pharmacy and buying over the counter medications in order to attend to their symptoms.

The purpose of today’s article, is to educate you about the different indicators of potential vaginal infections, and to instruct you about some behavioral modifications in order to aid in the management of existing and the prevention of future infections.

What is vaginal discharge?

Starting with vaginal discharge, it is the term doctors use to describe any fluid coming out of the vagina, regardless of its actual source (vagina, cervix, uterus…). This is actually one of the most common chief complaints for patients. This discharge can be completely normal. Actually, all pre-menopausal women will experience a small (2-5 millilitres) daily amount of clear/white mucus-like mostly odorless vaginal discharge.

This discharge fluctuates during the woman’s cycle (increases 1-2 weeks before the period) and differs from a woman to another; some experience minimal physiologic (normal) discharge, and others experience copious yet also normal discharge. This fluid actually is a marker of a healthy vagina! Because the more naturally lubricated the vagina is, the more likely is for you to see this physiologic discharge. In fact, after menopause (defined as 12 consecutive months without period) the vaginal mucosa (inner lining of the vagina) “dries out” secondary to the lack of hormonal stimulation, and thus the discharge decreases significantly.

Also, it is important for you to know that if you are on birth control pills, or in case of pregnancy, the physiologic discharge is expected to increase from baseline.

So, a small amount of clear/whitish non foul-smelling discharge that fluctuates within a menstrual cycle is totally normal. Actually, this discharge is beneficial because it helps in decreasing the risk of urinary and vaginal infections as it contains “good” bacteria (collectively named: normal vaginal flora)

 

When is vaginal discharge abnormal?

Before judging whether a discharge is normal or abnormal, always know yourself! Because you know yourself better than anyone else, so any dramatic change in the discharge should raise suspicion for a potential infection. The first thing you should look at, is the discharge itself. As I previously mentioned, a clear/white sparse discharge with no foul smell is most likely normal and physiologic, so any change in the consistency, color or smell of a discharge can signify an underlying infection.

So, a vaginal discharge is more likely to be associated with an infection if:

• It has a bad smell
• It is green, yellow, grey or bloody in color
• It is more copious than usual
• It is thick, foamy and chunky (with big particles clumping together)

Besides the discharge itself, you should be totally aware of other associated new symptoms such as:

• Painful intercourse (pain during sex, either from the outside or from the inside with deep penetration)
• Bleeding during or after sex
• Itching “down there”
• Burning sensation with or without urination
• Redness and\or swelling around the vagina
• Fever or chills
• Lower abdominal pain

In case you are suffering from any of the previously mentioned symptoms in addition to vaginal discharge, the probability for you to have a genital infection (vaginal, cervical or uterine) approaches 100%.

 

What can cause abnormal vaginal discharge?

So, it is clear by now that an underlying infection (bacterial, fungal or parasitic) is the most probable cause for abnormal vaginal discharge. However, sometimes this discharge occurs as a vaginal reaction to foreign bodies. You might find that strange but sometimes women lose a condom or tampon in their vaginas! And the first sign for such a foreign body is copious foul-smelling discharge, so always keep this option in the back of your minds.

Also, another common reason for changes in the vaginal discharge is a reaction to a new soap or other scented products (creams, powders, perfumes…) applied in the vagina. This is also applicable to the products used in vaginal douching (rinsing the insides of your vagina) which can cause more harm than benefit (will be discussed later).  

 

Most common infections causing vaginal discharge

Now we will go through the most common infectious reasons for abnormal vaginal symptoms.

Bacterial Vaginosis (BV)

This is the most common cause of abnormal vaginal discharge in women. There are different bacterial strains that can cause BV, but the main reason behind it is a reduction in the normal vaginal flora (beneficial vaginal bacteria) and thus an increase in the number of pathological bacteria. 

Symptoms include a foul smell that is typically described as “fishy smell”, especially more noticeable after sex. Also, the discharge is typically off-white and thin. Affected women are less likely to experience pain, burning sensation, redness, swelling, fever or chills.

Even though bacterial vaginosis is not classified as a sexually transmitted infection, yet one of its commonly reported risk factors is having multiple or new sexual partners. Also, women who have sex with women are at an increased risk for bacterial vaginosis compared to heterosexual women. Moreover, smoking and vaginal douching are recognized as important risk factors for this infection, because they both alter the normal protective vaginal flora.

The diagnosis should be made by your clinician! A home-based diagnosis is not accurate and thus you should follow with your gynecologist in case of any of the above-mentioned symptoms. It is always advisable to never self-medicate in case of any suspected vaginal infection, as you may make things worse! The treatment is simple, either oral or vaginal (cream or gel) antibiotics. If symptoms improve after treatment course, a follow up visit is not necessary.

I will not go through the names and doses of the antibiotics that can be used, but you should know that in case you were prescribed the famous Flagyl pills (metronidazole) avoid Alcohol consumption as these two strongly interact.
Male partners treatment is not indicated, but female partners treatment is usually indicated especially in the setting of symptoms in the female partner.
Avoid sex during the treatment period.

 

Vaginal Yeast Infection (Candida)

Also, a common reason for vaginal infection is Candida. Patients  usually present with burning sensation “down there” exacerbated by urination, in addition to itching and irritation along with copious thick white cottage cheese like (curd-like) discharge. The most famous causative agent is Candida which is considered part of the normal vaginal flora, however, in the setting of altered environment it can overgrow and cause symptoms.
The main risks for developing yeast infections are, diabetes, weak immune system (HIV, chemotherapy, steroid use…), pregnancy, vaginal douching, recent intake of antibiotics for any reason and estrogen containing birth control methods.

Here again, Candida is NOT a sexually transmitted infection, but it is more commonly seen in women who are sexually active.

The diagnosis should be made by your clinician! Also, women are discouraged from self-medicating with over the counter anti-fungal creams or pills. Actually, a study showed than only 11% of women in the States accurately diagnosed their infections! So, self-diagnosis and self-treatment will most likely waste your time, money and efforts, and may even worsen your symptoms.
Once the diagnosis is made, treatment can be introduced with the use of either vaginal or oral anti-fungal medications. You are expected to notice a positive effect in few days after treatment initiation. Treatment of your partner (male or female) is NOT indicated (unless the female partner has symptoms). Again, avoid sex during the treatment period.

Some patients ask about diet changes and the use of supplements to treat and prevent vaginal yeast infections, but the fact is that there are no strong studies to advocate for such practices. Actually, the use of probiotics, garlic or other food supplements to decrease the risk of vaginal thrush is not proven yet. The only clear benefit was seen after implementing a healthier diet for better blood sugar control in the setting of diabetes. 

 

Trichomoniasis or Trich!

Trichomoniasis is a sexually transmitted infection that can cause symptoms in both males and females. Most men do not have any symptoms, yet women tend to show symptoms more often than men. In women, the most commonly reported symptoms are:

• Foul smelling foamy greenish-yellow discharge
• Itching and burning of the vagina and area around the vagina
• Minimal bleeding (spotting) after sex
• Pain during sex
• Pain or burning during urination

In men, the reported symptoms are, pain or burning during urination in addition to abnormal penile discharge.  

The most important risk factor for this infection is having new or multiple sexual partners as it is a sexually transmitted infection.

Here again, you should never start any over the counter medication without consulting with your physician, as the diagnosis is only made on clinical grounds by a specialist. Once the diagnosis is confirmed, treatment is usually initiated with oral pills (no vaginal therapy for this infection).

All your sexual partners for the past 60 days should be treated as well.

Also bear in mind that if you were diagnosed with trichomoniasis, screening for all other sexually transmitted infections becomes warranted (HIV, Gonorrhea, Chlamydia, hepatitis B)

 

Chlamydia and Gonorrhea

Finally, one of the most commonly seen infections causing abnormal vaginal discharge are Chlamydia and Gonorrhea. Both are sexually transmitted infections and can cause abnormal foul smelling greenish discharge, in addition to abnormal vaginal bleeding, abdominal pain, pain during sex, burning upon urination and fever or chills.

The diagnosis should be made by a specialized clinician as it is crucial to know whether the infection is localized to the vagina and cervix or has spread to the uterus (known as pelvic inflammatory disease). Antibiotics are the mainstay of therapy and you should abstain from sex for at least 7 days after initiation of therapy.

Here similarly, all your partners for the past 60 days should be treated and should abstain as well.

Again, you should be tested for other sexually transmitted infections in case of a positive result for either Chlamydia or Gonorrhea.  

 

What to do?

So, in a nutshell, in case you have any changes in your vaginal discharge patterns, in terms of amount, smell, color and consistency you should seek medical advice.

Also in case you have associated, abdominal pain, fever, chills, itching, burning sensation, pain during sex or abnormal bleeding patters, consult with your physician.

You are not advised to self-diagnose and self-medicate without seeking a professional opinion.

In the setting of sexually transmitted infections, you and all your partners (males and females) for the past 60 days should be tested and treated, and you will have to do a full STI panel screening.

Some infections cannot be managed with vaginal creams or ovules, as you might need oral therapy (follow with your physician)  

 

How to prevent?

The key in the prevention of unwanted vaginal infections, is to avoid certain habits and implement healthier practices.

You should AVOID the following:

• Vaginal douches (rinsing the insides of your vagina)
• Wearing pantyliners/pads every day
• Scented vaginal sprays, powders, perfumes or washes
• Bubble baths or other scented bath products
• Wearing tight synthetic clothing (especially in hot climates)
• Taking invalidated anti-fungal and anti-bacterial medications
• Having sex when you have any of the previously-mentioned symptoms of infection
• Unprotected non-monogamous sexual intercourse 

 

You should IMPLEMENT the following:

• Use water or unscented cleanser to wash the genital area (use warm water and your hand instead of hot water and a cloth)
• In case of a foul smell, do not douche to get rid of the smell, instead see a health care provider
• Wear cotton underwear
• Rinse genitals with water and/or pat dry after toileting instead of using baby wipes or scented toilet papers.
• Have better control of your chronic medical condition (diabetes, low immune state…)
• Use barrier contraception (such as condoms)
• Change out of wet and tight clothing as soon as possible (avoid hanging out in your wet swimwear) 

In conclusion, not all vaginal discharges are abnormal, but any change in your usual discharge, and any new associated symptoms should raise suspicion for a potential underlying infection and should incite you to seek professional medical advice.

Karam 

Disclaimer: This article mainly applies to pre-menopausal women in their reproductive age. In the setting of abnormal vaginal discharge in young girls (before any period) and older ladies (after the age of menopause) the differential diagnosis changes totally, so always follow with a specialist!