Bacterial Vaginosis

“I have itching, burning, irritation and/or abnormal discharge DOWN THERE!? What is HAPPENING to me?! This is so embarrassing!”

Let’s break it down and see the possible causes; what you need to do now and what you need to do in the future. Ultimately, this post is guidance and to give you a better understanding of what may be happening and why. You need to see your primary care to get the proper diagnosis. My goal is to teach and help you understand about certain infections.

If you have been itching, burning or having an abnormal discharge, you might be suffering from a type of vulvovaginitis, which is inflammation of the vulva or vagina. It could be mild or severe. It could occur for the first time and not come back again, or come back again often. In order to treat it appropriately, the type needs to be identified. Is it a yeast infection? Is it bacterial vaginosis? Is it trichomoniasis?

The most common cause of vaginitis is bacterial vaginosis (BV). The next common cause is candidiasis and then it is trichomoniasis. They affect the vulva and the vagina, but other infections can also affect these areas, such as sexually transmitted diseases like herpes, syphilis, chalmydia, gonorrhea. Often when women have vulvovaginitis, they do not have symptoms (70% of the time).

If you are having the symptoms for the first time, you should see your doctor without doing any self-treatment based on what you have read on the internet. Get it diagnosed. What is the cause? If you do self-treatment with nonprescription medications, it may compromise the evaluation. I highly recommend going to your primary care and getting it evaluated not to a blog or youtube channel that gives home remedies.

What will happen during the doctor visit? You will be asked a series of questions then have a speculum examination done to obtain a sample to do various tests on. Then a diagnosis is given and a treatment.

Let’s talk about the normal vulva and vagina:
The vulva contains hair follicles and sebaceous, sweat and apocrine glands. While the vagina does not have these things but is made up of nonkeratinized cells. The vagina is influenced by estrogen stimulation. After puberty, the vaginal tissues will react to estrogen and it will increase glycogen levels which will favor the growth of specific bacteria, lactobacilli, which are the good bacteria. They break down the glycogen into lactic acid and brings the pH at a range of 3.5 – 4.5. This pH level is normal after puberty and before menopause. So, if you test the vaginal pH and have anything above 4.5, this would be abnormal.

Discharges:
There are normal discharges from the vagina. So, do not freak out when you have a discharge. You can have mucus coming from the cervix, exudates from accessory glands, exfoliated squamous cells from the vaginal wall. It could lead to white or off-white color and provides an increased consistency. This is normal. The amount varies depending on many factors, which includes your hormones, hydration status, pregnancy, immunosuppression, and inflammation. Normal vaginal secretions do not have an odor. So, discharge can be normal, but if you ever have an odor — THIS IS NOT NORMAL. No, you won’t normally have a perfume like smell, but you shouldn’t have a bad smell. Pay attention to the smell and if it seems different, bad, then this could be a sign of an infection.

Let’s talk about bacterial vaginosis.
This is due to low levels of the normal bacteria (lactobacilli) and an overgrowth of anaerobic organisms. I know this might be a bit much, but the lactobacilli (the good bacteria in the vagina) produce hydrogen peroxide that breaks down glycogen, which is produced by the vaginal tissues. This causes the pH low to be low (between 3.5-4.5). So, the normal vaginal pH should be between 3.5-4.5. And in bacterial vaginosis you have lower than normal amounts of the lactobacilli, the pH will be higher than normal. This causes overgrowth of the bad bacteria in the vagina. In BV there is this musty or fishy odor and a gray-white to yellow discharge and a pH above 4.5. When you visit your primary care, they will take do a speculum exam and take a sample to check pH, look for clue cells under the microscope (clue cells are epithelial cells with clumps of bacteria clustered on their surfaces).

So, in BV you have abnormal gray discharge, pH level of greater than 4.5 and positive whiff test and presence of clue cells. They are treated with metronidazole oral or topical, or you can be treated with clindamycin. If you are pregnant, you can still be treated with these drugs as they are not teratogenic (these drugs won’t affect your pregnancy).

Vulvovaginal Candidiasis
This is caused by airborne fungi, 90% of it is Candida albicans. This is NOT an STI and they do not generally coexist with other infections. This is more likely to occur in pregnant women, patients on broad-spectrum antibiotics, diabetics, obese, immunosuppressed, those on OCP, those on corticosteroids. Wearing tight clothing or keeping a warm and moist environment can increase candida infection. the most common symptom is itching. But up to 20% of women are asymptomatic. Burning, ezxternal dysuria and dyspareunia are also findings. There is a discharge that looks like cottage cheese. They have a pH of 4 to 4.5. It is odorless. You can have a reliable diagnosis based on history and physical exam alone. OTC treatments are safe and effective but if they do not respond to OTC treatment or they have recurrence soon after treatment should have a definitive diagnosis. If you are self-treating, before visiting the doctors, you need to stop the treatment for three days prior to visiting the doctors. Diagnosis will require visualization of blastospores or pseudohyphae on saline or 10% KOH microscopy or a positive culture in symptomatic woman. Latex agglutination tests may be used if it is a non-Candida albican strain because they do not demonstrate pseudohyphae on wet prep. Treatment requires the topical application of imidazole (miconazole, clotrimazole, butoconazole or terconazole in cream or suppository form placed intravaginally. Or a short-term oral therapy with low0dos *150mg) of fluconazole. Pregnant women should be treated with topical agents due to an increase in the risk of birth defects associated with high obese (400-800) of fluconazole. Although it has high cure rates, there is still a 20-30% chance of recurrence after 1 month. There is an option of weekly therapy with fluconazole for 6 months, which has been shown to be effective in preventing recurrent candidiasis in 50% of women. Intermittent therapy with topical agents weekly or twice weekly can be used as preventative care. When a patient is given antibiotics for systemic inflammation, they should be prescribed antifungal for ppx.

Trichomonas vulvovaginitis
This is an infection that is transmitted through sexual contact but can occur from fomites (poop) and oht tubs. It is assoicated with PID, endometritis, infertility, ectopic pregnancy and preterm birth. It often coexists with other sexually transmitted disease and BV. It has also been shown to facilitate HIV transmission. It can present with itching, burning copious discharge and an odor, as well as pain during urination and during sex. The discharge is often frothy, thin, yellow-green in color but even gray in color. pH is above 4.5. There may be edema or erythema of the vulva. On exam there could be strawberry patches in the cervix, but this is not often seen in every case. The diagnosis is confimred by microscopic examination of vaginal secretions in normal saline. THis wet smea will show large mature epithelial cells with WBC and trichomonas organisms. Those that are diagnosed with this should be screen for other STDs esepcially gonorrhea and chlamydia. It is treated with oral metronidzaole or tinidazole. Their sexual parter needs to be treated as well other wise it will lead to reinfection due to the partner not being treated because they stil lhave it. When on this medication, abstaine from alcohol because it will lead to disulfiram like reaction. Trichomoniasis is assosited with preterm delievery, PROM and low brith weight. Pregnant patiens should be treated and metronixazole is considered safe for use during pregnancy. However, treatemtn may not prevent these pregnacy complications. They do not need to be followed-up to see if it is gone. it is not cost- effective.

BV and trichomoniasis can be hard to distinguish so if you have symptoms, it is important to get it diagnosed. If it is trichomonias, you have these protozoans in the vaginal that need to be eliminated by metronidazole and also your partner needs to be treated for it.