REPROSAIT 4 U

What is cytolytic vaginosis?

Cytolytic vaginosis is an occasional cause of vaginal discharge.

What is the cause of cytolytic vaginosis?

The normal vagina of an adult woman is colonised by lactobacilli. These bacteria produce lactic acid, which maintains an acid pH, and hydrogen peroxide, which is an antiseptic agent. The lactobacilli protect the vagina from pathogenic infections and are considered important for vaginal health.

Cytolytic vaginosis arises because of an overgrowth of the lactobacilli. They can irritate the cells that make up the vaginal lining, causing them to break up. The damaged or fragmented cells are then shed with the normal vaginal secretions.

What are the symptoms?

Many women with cytolytic vaginosis are unaware of it. It may be reported after a vaginal swab or cervical smear. However, they may have the following symptoms:

• Abundant whitish vaginal discharge, which may be thin and watery or thick and curd-like
• Vaginal and/or vulval itching (pruritus vulvae)
• Burning (vulvodynia), especially on passing urine (dysuria)
• Discomfort during sexual intercourse (dyspareunia)

The symptoms are similar to those of vaginal thrush. Like thrush, they may get worse in the second half of the menstrual cycle. However, high vaginal swabs do not culture the yeast that causes thrush, Candida albicans, and antifungal creams and tablets are not effective. The vaginal pH is acidic (3.3 to 5.5).

How is the diagnosis made?

Cytolytic vaginosis should be considered in women with vaginal symptoms that have not settled down or have recurred after treatment for thrush.

A vaginal swab should be taken. The laboratory may report numerous lactobacilli and epithelial cells. There should be no sign of candida or other infective organisms.

What is the treatment for cytolytic vaginosis?

In most women, no specific treatment is required. Antifungal medications should be discontinued.

In those with symptoms, the following measures may be helpful:

1. Pads instead of tampons for menstruation.
2. Baking soda (sodium bicarbonate) sitz baths or douches to increase vaginal pH and thus discourage the growth of lactobacilli. Use 2-4 tablespoons of baking soda in 5cm of water in a warm bath several times in a week, then once or twice per week to prevent recurrences.

Vulvovaginal Candidiasis

Vulvovaginal candidiasis is the name often given to Candida albicans infection of the vagina associated with a dermatitis of the vulva (an itchy rash). ‘Vaginal thrush’, and ‘monilia’ are also names for Candida albicans infection.

What causes vaginal discharge?

Most women notice from time to time that they have a discharge from the vagina. This is a normal process which keeps the mucous lining of the vagina moist. The discharge is usually clear but may dry on underclothes leaving a faint yellowish mark. This type of discharge does not require any medication even when quite profuse, as is often the case in pregnancy.

Vaginal discharge may also be due to microorganisms:

1. Vulvovaginal candidiasis (discussed here).
2. Trichomoniasis (due to a small parasite,Trichomonas vaginalis). This causes a fishy or offensive odour and yellow, green or frothy discharge.
3. Bacterial vaginosis (due to an imbalance of the amounts of bacteria which live in the vagina). This causes a thin, white/grey discharge and offensive odour.
4. Cytolytic vaginosis (due to an overgrowth of lactobacilli).

Excessive vaginal discharge may also be due to injury, foreign bodies and other causes of vaginitis.

What is the cause of vulvovaginal candidiasis?

About 20% of non-pregnant women aged 15 to 55 harbour Candida albicans in the vagina. Most have no symptoms and it is harmless to them. Overgrowth of Candida albicans causes a heavy white curd-like vaginal discharge, a burning sensation in the vagina and vulva and/or an itchy rash on the vulva and surrounding skin.

Candidal vulvovaginitis on a wet smear. Addition of potassium hydroxide here has made the hyphae more apparent. Arrows indicate budding yeast. (Courtesy of Pharmacia and Upjohn.)

Gram's stain of Candida organisms in vaginal secretions. Spores and hyphae (staining red/purple) as well as normal bacterial flora are seen. Arrows show buds and hyphae. (Courtesy of CDC.)

Oestrogen causes the lining of the vagina to mature and to contain glycogen, a substrate on which Candida albicans thrives. Lack of oestrogen in younger and older women makes vulvovaginal candidiasis much less common.

Overgrowth of Candida albicans occurs most commonly with:

1. Pregnancy
2. Higher dose combined oral contraceptive pill and oestrogen-based hormone replacement therapy
3. A course of broad spectrum antibiotics such as tetracycline or amoxiclav
4. Diabetes mellitus
5. Iron deficiency anaemia
6. Immunological deficiency e.g., HIV infection
7. On top of another skin condition, often psoriasis, lichen planus or lichen sclerosus.
8. Other illness

What are the symptoms?

Symptoms of vulvovaginal candidiasis, i.e., an overgrowth of Candida albicans, include:

1. Itching, soreness and/or burning discomfort in the vagina and vulva
2. Heavy white curd-like vaginal discharge
3. Bright red rash affecting inner and outer parts of the vulva, sometimes spreading widely in the groin to include pubic areas, inguinal areas and thighs.

These may last just a few hours or persist for days, weeks, or rarely, months.

Symptoms may sometimes be aggravated by sexual intercourse.

How is the diagnosis made?

The doctor diagnoses the condition by inspecting the affected area and recognising typical clinical appearance. The pH of the discharge tends to be less than 4.5 the diagnosis is often confirmed by a vaginal swab. In recurrent cases the swab should be repeated after treatment to see whether Candida albicans is still present.

It is best to avoid treatment for four weeks prior to a swab to improve the chance of positive culture.

Swab results can be misleading because the Candida albicans can be present without causing symptoms, and it can only be cultured if a certain amount is present. Swabs from outside the vagina can be negative, even when the yeast is present inside the vagina and there is a typical rash on the vulva. This is because the vaginal discharge has caused an irritant dermatitis, rather than the rash being directly due to infection.

Some women with recurring vulvovaginal symptoms appear to be hypersensitive to the organism (cyclic vulvovaginitis). In these cases it may be difficult for the laboratory to detect the yeast as a vigorous dermatitis has eradicated it.

In other cases, a different species of yeast i.e. a non-albicans candida is found. This is not likely to cause significant vulvovaginitis. Antifungal agents may not clear non-albicans candida from the vagina but luckily, it tends to disappear in time by itself.

Similar symptoms may occur from cytolytic vaginosis.

Treatment

Appropriate treatment for Candida albicans infection can be obtained without prescription from a chemist. If the treatment is ineffective or symptoms recur, see your doctor for examination and advice.

There are a variety of effective treatments for candidiasis. Topical antifungal pessaries or vaginal tablets are usually recommended – in mild cases a single treatment is all that is necessary. A cream formulation may be preferred. Oral antifungal medicines may be used if Candida albicans infection is severe or recurrent.

The creams can be used safely in pregnancy, but the tablets are best avoided.

Not all genital rashes are due to candida, so if treatment is unsuccessful it may because you have another reason for itching (pruritus vulvae) or burning (vulvodynia).

Recurrent Candidiasis

Occasionally Candida albicans infection persists despite adequate conventional therapy. In some women this may be a sign of iron deficiency, diabetes mellitus or an immune problem, and appropriate tests should be done.

It is now thought that women who experience recurrent vulvovaginal Candida albicans do so because of persistent infection, rather than re-infection. The aim of treatment in this situation is therefore to avoid the overgrowth of candida that leads to symptoms, rather than necessarily being able to achieve complete eradication or cure.

There is some evidence that the following measures can be helpful:

1. Cotton or moisture-wicking underwear and loose fitting clothing – avoid nylon pantyhose.
2. Soaking in a salt bath. Avoid soap – use a non-soap cleanser or aqueous cream for washing.
3. Apply hydrocortisone cream to reduce itching and treat secondary dermatitis affecting the vulva.
4. Treat with an antifungal cream before each menstrual period and before antibiotic therapy to prevent relapse.
5. A prolonged course of a topical antifungal agent is occasionally warranted (but these may themselves cause dermatitis or result in proliferation of non-albicans candida).
6. Oral antifungal medication (itraconazole or fluconazole) may be taken regularly and intermittently (e.g. once a month). The dose and frequency is quite variable, depending on the severity of symptoms. Oral antifungal agents may be unsuitable in pregnancy. They require a prescription.
7. Boric acid (boron) 600mg as a suppository at night may help to acidify the vagina and reduce the presence of yeasts (albicans and non-albicans candida).

What is trichomoniasis?

Trichomoniasis, sometimes referred to as "trich", is a common cause of vaginitis. It is caused by the single-celled protozoan parasite Trichomonas vaginalis. Trichomoniasis is primarily an infection of the urogenital tract; the most common site of infection is the urethra and the vagina in women.

Trichomoniasis is a common sexually transmitted disease (STD) that affects both women and men, although symptoms are more common in women.

How common is trichomoniasis?

Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men.

How do people get trichomoniasis?

Trichomoniasis is caused by the single-celled protozoan parasite, Trichomonas vaginalis. The vagina is the most common site of infection in women, and the urethra (urine canal) is the most common site of infection in men.

The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva (the genital area outside the vagina) contact with an infected partner. Women can acquire the disease from infected men or women, but men usually contract it only from infected women.

What are the signs and symptoms of trichomoniasis?

Most men with trichomoniasis do not have signs or symptoms; however, some men may temporarily have an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation.

Some women have signs or symptoms of infection which include a frothy, yellow-green vaginal discharge with a strong odor. The infection also may cause discomfort during intercourse and urination, as well as irritation and itching of the female genital area. In rare cases, lower abdominal pain can occur. Symptoms usually appear in women within 5 to 28 days of exposure.

What are the complications of trichomoniasis?

The genital inflammation caused by trichomoniasis can increase a woman’s susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis may increase the chance that an HIV-infected woman passes HIV to her sex partner(s).

How does trichomoniasis affect a pregnant woman and her baby?

Pregnant women with trichomoniasis may have babies who are born early or with low birth weight (low birth weight is less than 5.5 pounds)

How is trichomoniasis diagnosed?

For both men and women, a health care provider must perform a physical examination and laboratory test to diagnose trichomoniasis. The parasite is harder to detect in men than in women. In women, a pelvic examination can reveal small red ulcerations (sores) on the vaginal wall or cervix.

What is the treatment for trichomoniasis?

Trichomoniasis can usually be cured with prescription drugs, either metronidazole or tinidazole, given by mouth in a single dose. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect or re-infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms. Metronidazole can be used by pregnant women.

Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.

How can trichomoniasis be prevented?

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of trichomoniasis.

Any genital symptom such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately.

A person diagnosed with trichomoniasis (or any other STD) should receive treatment and should notify all recent sex partners so that they can see a health care provider and be treated. This reduces the risk that the sex partners will develop complications from trichomoniasis and reduces the risk that the person with trichomoniasis will become re-infected.

Sex should be stopped until the person with trichomoniasis and all of his or her recent partners complete treatment for trichomoniasis and have no symptoms.

What is Bacterial Vaginosis?

Bacterial vaginosis is vaginal condition that can produce vaginal discharge and results from an overgrowth of normal bacteria in the vagina. In the past, the condition was called Gardnerella vaginitis, after the bacteria that were thought to cause the condition. However, the newer name, bacterial vaginosis, reflects the fact that there are a number of species of bacteria that naturally live in the vaginal area and may grow to excess. The Gardnerella organism is not the sole culprit causing the symptoms. When these multiple species of bacteria become imbalanced, a woman can have a vaginal discharge with a foul odor.

Bacterial vaginosis is not dangerous, but it can cause disturbing symptoms. Any woman with an unusual discharge should be evaluated so that more serious infections such as chlamydia and gonorrhea, can be excluded.

What are the symptoms of Bacterial Vaginosis?

The symptoms of bacterial vaginosis are vaginal discharge and odor. Usually, there are no other symptoms. The amount of vaginal discharge that is considered normal varies from woman to woman. Therefore, any degree of vaginal discharge that is abnormal for a particular woman should be evaluated.

Many women with bacterial vaginosis actually have no symptoms at all. Others experience an unpleasant fishy odor with vaginal discharge. The discharge is usually thin and grayish white. The discharge is often more noticeable after sexual intercourse.

What causes Bacterial Vaginosis?

Researchers have had difficulty determining exactly what causes bacterial vaginosis. At present, it seems to be that a combination of multiple bacteria must be present together for the problem to develop. Bacterial vaginosis typically features a reduction in the number of the normal hydrogen peroxide-producing lactobacilli in the vagina. Simultaneously, there is an increase in concentration of other types of bacteria, especially anaerobic bacteria (bacteria that grow in the absence of oxygen). As a result, the diagnosis and treatment are not as simple as identifying and eradicating a single type of bacteria. Why the bacteria combine to cause the infection is unknown.

Certain factors have been identified that increase the chances of developing bacterial vaginosis. These include multiple or new sexual partners, vaginal douching, and cigarette smoking. However, the role of sexual activity in the development of the condition is not fully understood, and bacterial vaginosis can still develop in women who have not had sexual intercourse.

How is Bacterial Vaginosis diagnosed?

When a woman reports an unusual vaginal discharge, the doctor will ask her a series of routine questions to help distinguish mild from more serious conditions. Additional issues that might indicate the presence of a more serious condition include fever, pelvic pain, new or multiple sexual partners (especially with unprotected intercourse), and a history of sexually-transmitted infections.

In addition to these questions, the doctor will perform a pelvic exam. During the exam, the doctor notes the appearance of the vaginal lining and cervix. The doctor will also perform a manual exam of the ovaries and uterus. The cervix is examined for tenderness, which might indicate a more serious infection. The doctor may collect samples to check for chlamydia or gonorrhea infection.

Examining the vaginal discharge under the microscope can help distinguish bacterial vaginosis from yeast vaginitis (candidiasis) and trichomonas (a type of sexually transmitted infection). A sign of bacterial vaginosis under the microscope is an unusual vaginal cell called a clue cell. Clue cells are believed to be the most reliable diagnostic sign of bacterial vaginosis. In addition to clue cells, women with bacterial vaginosis have fewer of the normal vaginal bacteria, called lactobacilli. A vaginal pH greater than 4.5 is also suggestive of bacterial vaginosis.

Finally, the doctor may perform a "whiff test" with potassium hydroxide (KOH) liquid. When a drop of KOH testing liquid used in the "whiff test" contacts a drop of the discharge from a woman with bacterial vaginosis, a certain fishy odor can result.

What is the treatment for Bacterial Vaginosis?

Treatment for bacterial vaginosis consists of antibiotics. A few antibiotics are routinely used. Metronidazole (Flagyl) taken by either oral (pill) form or by vaginal metronidazole gel (Metrogel) is an effective treatment. Also available is the vaginal clindamycin cream (Cleocin). The oral metronidazole can cause some minor but unpleasant side effects, but is believed to be the most effective treatment. The gels do not typically cause side effects, although yeast vaginitis can occur as a side effect of the medication.

Tinidazole is an antibiotic that appears to have fewer side effects than metronidazole and is also effective in treating bacterial vaginosis.

Recurrence of bacterial vaginosis is possible even after successful treatment. More than half of those treated experience recurrent symptoms within 12 months. It is unclear why so many recurrent infections develop. With recurrent symptoms, a second course of antibiotics is generally prescribed.

What are complications of Bacterial Vaginosis?

Bacterial vaginosis can resolve completely without complications after treatment. No special follow-up is necessary if the symptoms disappear.

In pregnancy, bacterial vaginosis can cause premature labor, premature birth, infection of the amniotic fluid, and infection of the uterus after delivery. However, treatment of asymptomatic (not producing symptoms) bacterial vaginosis in pregnancy has not been shown to decrease the incidence of premature births in most studies. For these reasons, screening and treatment for bacterial vaginosis during pregnancy is controversial, and research is still being conducted to determine its utility and value. Currently the routine screening of all pregnant women is not recommended. However, screening and treatment of bacterial vaginosis is sometimes recommended for women with a history of a preterm birth.

Bacterial Vaginosis At A Glance

1. Bacterial vaginosis is an abnormal vaginal condition that is characterized by vaginal discharge and results from an overgrowth of normal bacteria in the vagina.
2. Bacterial vaginosis is not dangerous, but it can cause disturbing symptoms.
3. Symptoms of bacterial vaginosis are vaginal discharge and odor, although 50% to 75% of women with the condition experience no symptoms.
4. In diagnosing bacterial vaginosis, it is important to exclude other serious infections, such as gonorrhea and chlamydia.
5. Treatment options for bacterial vaginosis include oral antibiotics ( metronidazole , tinidazole , clindamycin ) oral and topical vaginal gels.
6. Serious complications of bacterial vaginosis can occur during pregnancy, and recurrence is possible even after successful treatment.