How to best know and treat vaginal discharge
How to best know and treat vaginal discharge

How to best know and treat vaginal discharge: Vaginal discharge can be harmless or deserving of therapy. Experts explain how to make the correct diagnosis and determine appropriate treatment.

Any bodily discharge can be embarrassing. If you don’t know how to hygienically cope with vaginal discharge, you may have issues with odor and/or staining that can lead to additional embarrassment. While many discharges are normal and help keep the pH balance of your vagina intact, other discharges can be the sign of real issues that need to be addressed either with over-the-counter medication or by seeing a qualified doctor.

 

Most women find changes in vaginal discharge distressing. Too often women attribute symptomatic discharge (e.g., one that is off-color, has a foul odor, and causes burning or itching) to a yeast infection, which they attempt to self-treat with an OTC remedy. In most cases, however, the problem is not a yeast infection but bacterial vaginosis (BV). And only a health-care provider can make the diagnosis and determine what treatment is necessary.

Even a change in discharge quantity may be distressing. Women taking oral contraceptives often report an increase in discharge. But this is normal since hormones cause a thickening of the cervical mucus, which impedes the progress of sperm.

Setting the stage for vaginitis The purpose of normal physiologic vaginal discharge is to lubricate the vagina.

 

What Is Vaginal Discharge?

Vaginal discharge is a fluid or semisolid substance that flows out of the vaginal opening. Most women have vaginal discharge to some extent, and a small amount of vaginal discharge is a reflection of the body’s normal cleansing process. The amount and type of vaginal discharge also varies among women and with the woman’s menstrual cycle. A change in vaginal discharge (such as an abnormal odor or color or increase in amount), or the presence of vaginal discharge associated with irritation or other uncomfortable symptoms, can signal that an infection is present.

 

 

What Is It?

Harvard Health Publications

Normally, vaginal discharge is clear or white. It may become stretchy and slippery during ovulation, about two weeks after your menstrual period. A change in the color or amount of discharge, accompanied by other symptoms, may indicate that you have an infection.

The vagina normally contains bacteria. Bacterial growth is controlled and affected by many different factors, such as acid level (pH) and hormones. Anything that upsets this balance may increase your risk of infection or overgrowth of any of the normal bacteria or by yeast. Possible triggers include:

  • Antibiotic use
  • Birth control pills
  • Douching
  • Diabetes
  • Pregnancy
  • Stress
  • Tight or synthetic undergarments

Vaginal discharge may result from infection with:

  • Yeast, also called Candida, a type of fungi that is part of the normal flora of human skin but can also cause infections
  • Gardnerella, a type of bacteria found normally in the female genital tract that is the cause of bacterial vaginosis
  • Trichomonas, a type of protozoa, an organism made up of one cell

 

Facts about and Definition of Vaginal Discharge

  • Vaginal discharge is fluid that exits from the vaginal opening.
  • Some vaginal discharge is normal when infection is present there may be an increase in quantity or change in the appearance of vaginal discharge.
  • Bacterial vaginosis, a condition of unbalanced overgrowth of normal vaginal bacteria, is another common cause of abnormal vaginal discharge.
  • Infections such as trichomoniasis, gonorrhea, and Chlamydia (all STDs); and yeast infection can all cause vaginal discharge.
  • Vaginal discharge can be associated with other symptoms such as burning or itching.
  • Antibiotics are given for infections that cause vaginal discharge. The choice of antibiotic depends upon the specific infection.
  • Many causes of vaginal discharge can recur after successful treatment.

 

The vagina contains lactobacilli, which act as vaginal regulators and maintain a healthy acidic environment. Interference with these organisms, either by unnecessary applications of such products as vaginal deodorants and OTC antifungals or by douching, can alter normal functioning and leave women susceptible to vaginitis.

Vaginitis can often be attributable to contact dermatitis, which causes inflammation and does not have an actual infectious component. Determine what household or hygiene products patients are using and whether they have made any recent changes. Such products include anything that can come into contact with the vulva. Encourage patients to keep a diary of their symptoms and the products they use. Condoms, soaps, face wash that may drip during showering, shampoos, laundry detergent, and toilet paper can all be irritating to the vulva. Type of underwear (in terms of fabric and style) and, most importantly, the brand of feminine pads used should be considered too, since symptoms that are worse after menses may be related to the pads. Make special note of symptoms that are worse during work hours; patients often forget that the products they use at work may be different than those they use at home.

Of course, vaginitis can also be caused by bacteria and yeast. The causative agent must be identified by a medical provider. Medication used in the absence of true infection can destroy the necessary lactobacilli, in turn reducing the body’s natural ability to ward off bacteria.

Sorting out the symptoms

Symptoms can be truly diagnostic, or they can create confusion. Yeast (i.e., Candida) infections are often associated with white curdlike discharge, burning, and redness of the vulval tissue. Depending on the extent of the infection, there may be a significant amount of swelling as well. The discharge typically does not have a foul odor. Without proper treatment, the tissue can become damaged, slowing the healing process. Long-term insults to the vulval and vaginal tissue (recurrent infections or infections that continue due to improper treatment) can result in irreparable damage. This can lead to a condition known as vulvodynia. Intercourse can assist yeast organisms to enter and inhabit vulval tissue. If this is allowed to occur, patients may go on to have pain with intercourse; some patients have pain with just sitting or standing.

Diagnosing vulvodynia is quite difficult, and the condition is frequently missed. Patients with suspected cases should be referred to a specialist. Practitioners without proper training may recommend treatments that can further damage and destroy the tissue. Overtreatment of the vagina is as harmful as undertreatment.

The usual symptoms of BV are yellow or green vaginal discharge, burning, and a fishy odor. However, some symptoms are vague and need to be evaluated by a clinician. Intercourse tends to exacerbate symptoms; BV is not a sexually transmitted infection but rather a sexually associated infection. Symptoms are worsened by alterations in vaginal pH (normal 3.8-4.5), which can occur with the introduction of semen, menstrual blood, or douching.

 

Evaluating the Problem

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    See if your discharge is normal. Normal vaginal secretions will be clear or milky in appearance. This natural lubricant helps clean your vagina, keeping it free from unhealthy germs. Normal secretions are odor-free. Secretions may be thin, stringy or have white spots. If this sounds like your discharge, leave it alone. Natural discharge is very important in keeping your vagina healthy.
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    Learn the types of vaginal discharge. There are several different types of vaginal discharge. These types are categorized based on their color and consistency. Some are normal, while others may indicate an underlying condition that requires treatment.
    • Thick, white, cheesy discharge – This is usually a sign of a yeast infection. May also be accompanied itching or swelling around the vulva.
    • White, yellow or grey discharge – Especially if accompanied by a fishy odor, this type of discharge is likely a sign of bacterial vaginosis. May also be accompanied by itching and swelling.
    • Yellow or green discharge – A yellow or green discharge, especially when it is thick, chunky, or accompanied by a bad smell, is not normal. This type of discharge may be a sign of the infection trichomoniasis, which is commonly spread through sexual intercourse.
    • Brown or bloody discharge – Brown or bloody discharge may be a product of irregular menstruation, but can also be a sign of more serious illness such as cervical cancer if accompanied by pelvic pain or vaginal bleeding.
    • Cloudy yellow discharge – This type of discharge, especially if accompanied by pelvic pain, may be a sign of gonorrhea.
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    Consider the state of your body. Factors that affect vaginal discharge include what you eat, your menstrual cycle, whether or not you’re on the pill, if you are breast-feeding, what medications you are taking, whether or not you are pregnant, and whether or not you are under stress.
    • You can also be at risk of throwing off your vagina’s natural pH balance if you are on antibiotics or if you use vaginal douches, feminine hygiene products or perfumed soaps. While anti-biotics cannot be avoided, douching and scented feminine products should always be avoided as these are bad for your body.
    • Other things that can put you at risk include pregnancy, diabetes or other infections that are near or around that area of the body.
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    Look for foreign objects. Leaving in a tampon for too long can cause unusual discharge. Some women forget they even had a tampon up there! You can also end up with other objects in your vagina which can cause a discharge (as your body tries to expel it). A common example is a piece of a broken condom.
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    Know the difference between colors and odors of vaginal discharge. Off-color or foul odors in the vaginal region can be the sign of a pelvic infection after you’ve had a surgery, pelvic inflammatory disease (PID), vaginal atrophy during menopause, trichomoniasis or vaginitis, and several other vaginal infections, all of which should be diagnosed by a doctor and treated as advised by your doctor.
    • Vaginal discharge with bacterial vaginosis will be gray, white or yellow. It will also have a fishy odor.
    • If you have gonorrhea, you might have a cloudy or yellow discharge.
    • Yeast infections can be apparent if you have a thick, white discharge. This discharge is often described as having a cottage cheese consistency. Cottage cheese discharge is also characteristic of chlamydia, a common STI.
    • If you have an irregular period or endometrial or cervical cancer, you may notice a bloody or brown discharge.
    • If you have trichomoniasis, yellow/green frothy discharge that has a bad odor may affect you.
    • If you don’t have health insurance, there are clinics (like Planned Parenthood) which offer gynecological exams and treatment that are inexpensive or free.
    • Avoid taking medication until you know what the cause is. There is medication for things like yeast infections, but you should not self-diagnose a yeast infection if this is your first time getting one. Taking yeast infection medication without a yeast infection can lead to future problems.

 

What Are the Signs and Symptoms of Vaginal Discharge?

Vaginal discharge may range in color from clear to gray, yellow, greenish, or milky-white and may have an unpleasant smell. The symptoms and character of vaginal discharge depend upon the specific condition that is the cause of the discharge.

  1. Bacterial vaginosis:  is a condition that is caused by an imbalance in the growth of the bacteria that are normally present in the vagina. It is not known exactly why this imbalance in bacterial growth occurs. This condition was formerly known as Gardnerella vaginitis after one type of bacteria that commonly cause the condition. Not all women with bacterial vaginosis will have symptoms, but bacterial vaginosis typically produces a discharge that is thin and grayish-white in color. It is usually accompanied by a foul, fishy smell.
  2. Trichomonas: (trich) is infection by a single-celled parasite known as Trichomonas vaginalis. The infection is transmitted by sexual contact. Trichomonas infection produces a frothy, yellow-green vaginal discharge with a strong odor. Associated symptoms can include discomfort during intercourse and urination, as well as irritation and itching of the female genital area.
  3. Gonorrhea: is the sexually-transmitted disease (STD) resulting from infection by the bacteria known as Neisseria gonorrhoeae. Gonorrhea may not produce symptoms in up to half of infected women, but it can also cause burning with urination or frequent urination, a yellowish vaginal discharge, redness and swelling of the genitals, and a burning or itching of the vaginal area.
  4. Chlamydia: is another sexually-transmitted infection (STD) due to the bacteria Chlamydia trachomatis. Although infected women may not have symptoms, a vaginal discharge may occur. Like gonorrhea, Chlamydia infection may not produce symptoms in many women. Others may experience increased vaginal discharge as well as the symptoms of a urinary tract infection if the urethra is involved.
  5. Vaginal yeast infection: (candidiasis) occurs when there is an overgrowth of yeast in the vagina, often due to antibiotic use or other factors that affect the natural balance of bacteria in the vaginal area. Candida species are the type of yeast most commonly responsible. A vaginal yeast infection is usually associated with a thick, white vaginal discharge that may have the texture of cottage cheese. The discharge is generally odorless. Other symptoms can include burning, soreness, and pain during urination or sexual intercourse.

 

While Trichomoniasis, gonorrhea, and Chlamydia are examples of sexually-transmitted diseases (STDs), bacterial vaginosis and yeast infection are not considered to be STDs.

Vaginal bleeding is different from vaginal discharge. The infections listed above are causes of abnormal vaginal discharge without the presence of significant vaginal bleeding.

 

Vaginal Yeast Infection Symptoms

Most women experience at least one yeast infection during their lifetime, and they can be caused by many things. Symptoms of a yeast infection are intense itching of vaginal area, painful intercourse, and a vaginal discharge that is white-gray and thick, and has a resemblance of cottage cheese.

The need for prompt evaluation

Patients require quick access to a clinician. Anyone who has had a vaginal infection knows that the symptoms interrupt day-to-day life, and concentration at work or home can be impossible. Offering a woman the next available appointment two or more weeks later is going to cause her to seek relief with an OTC medication even if her discomfort is not due to yeast. We have witnessed non-clinician staff treating patients over the phone based on the same vague symptoms, often multiple times. Although these treatments may cure some patients, for others they will only compound the problem. The importance of evaluation cannot be stressed emphatically enough. Patients who are misdiagnosed continue to suffer, become frustrated, lose faith in you, and take longer to cure.

Laboratory or in-office testing

Various laboratories have different sample collection methods using different devices. If you do not use the correct collection media, your sample may die in transit. Please contact your local lab for the correct media to collect and transport your specimen.

You may also do your own in-office testing. Preparing a wet mount slide has become a lost art in most practices. Time constraints placed on each visit may make it seem impossible to prepare a wet mount for each patient who has a vaginal complaint. If you have the right materials and microscope, however, the procedure can be quick and productive.

The technique for collecting vaginal discharge for wet mounts currently used in our practice surpasses all other methods we have tried. This technique is cost-effective, requires few materials, and can result in immediate diagnosis and treatment (see “Diagnosing vaginitis—the role of pH paper, the whiff test, and microscopy”). This eliminates the use of an unnecessary or wrong medication and the need to call the patient back days later when the diagnosis is reported from the lab.

Possible results and the diagnosis they signify are presented in Table 1.

 

When Should You Seek Medical Care for a Vaginal Discharge?

It is appropriate to seek medical care any time you have a change in the character (color, odor, consistency) or amount of vaginal discharge or if you have other symptoms such as pain, burning, or itching of the vaginal area.

 

How Do Doctors Diagnose the Cause of Vaginal Discharge?

After reviewing your symptoms and medical history, the health-care professional will likely perform a pelvic examination, which includes examination of the external genital area and the insertion of a speculum to examine the vaginal walls and cervix.

Depending upon the examination, the health-care professional may take swabs of the vaginal discharge for culture or for examination under a microscope to help define the cause of the vaginal discharge.

 

What OTC Medications or Home Remedies Treat Vaginal Discharge?

Yeast infections may be treated using over-the-counter medications, but other causes of vaginal discharge require prescription medications. It is critical to take the entire course of medication as prescribed or recommended by your doctor, even if the symptoms improve. If you are uncertain as to the cause of your vaginal discharge, it is important to visit a health-care professional to determine the cause rather than starting OTC medications if you are unsure.

Some alternative medical approaches recommend douching for the treatment of some causes of vaginal discharge. However, douching is not recommended by most physicians. The body has a natural way of cleansing the vaginal canal by itself, and douching can disturb the normal environment of the vagina, potentially leading to inflammation and even worsening of the symptoms. The American College of Obstetricians and Gynecologists and most doctors recommend that women avoid douching unless specifically prescribed by a doctor.

What If My Sex Partner Has a Vaginal Discharge and Is Infected with an STD?

With sexually-transmitted infections such as gonorrhea, Chlamydia, and trichomonas, it is important for sex partners of the infected woman to be examined and treated to prevent further spread of the infection. A woman in a monogamous relationship may become re-infected if her partner is also not treated.

 

Can Vaginal Discharge Be Prevented?

Safe sex practices such as condom use can help prevent the spread of sexually-transmitted infections. It is not possible to completely prevent vaginal yeast infections and bacterial vaginosis, because the conditions arise due to an imbalance in the bacteria and organisms normally present in the vagina and their cause is not completely understood.

 

Which Types of Doctors Diagnose and Treat Vaginal Infections?

Vaginal discharge can be treated by primary care physicians such as family practitioners or pediatricians as well as internal medicine doctors and gynecologists.

 

What Prescription Medications Treat Vaginal Discharge?

The choice of medication depends upon the type of infection. Antibiotics and antifungal medications are the mainstay of treatment, administered either in topical, injection, or oral form, depending upon the particular infection.

Oral, injectable, and topical (applied as tablets or cream into the vaginal area) medications are used to treat the various causes of vaginal discharge.

  • A number of medications may be effective in the treatment of bacterial vaginosis, including metronidazole (Flagyl), tinidazole (Tindamax), and clindamycin cream (Cleocin). These medications are also effective in the treatment of trichomonas infections.
  • Trichomonas is treated either with metronidazole (Flagyl) or tinidazole (Tindamax), given by mouth in a single dose. It is important for sex partners to be treated at the same time to avoid re-infection.
  • In the past, penicillin was the drug of choice for treatment of uncomplicated gonorrhea. However, new strains of gonorrhea have become resistant to various antibiotics, including penicillins, and are therefore more difficult to treat. Gonorrhea may be treated by an injection of ceftriaxone (Rocephin) intramuscularly or by oral cefixime (Suprax). Other antibiotics may also be used.
  • Chlamydia is typically treated by oral azithromycin (Zithromax, Zmax) or doxycycline (Vibramycin, Oracea, Adoxa, Atridox and others).
  • Vaginal yeast infections can be treated by topical creams such as butoconazole (Gynazole 1), clotrimazole (Lotrimin), miconazole (Monistat 3, Monistat 5, Monistat 7, M-Zole Dual Pack, Micon 7), and terconazole (Terazol 3, Terazol 7). Nystatin (Mycostatin, bio-Statin, Nilstat) is also available in vaginal tablet form. Oral medications such as fluconazole (Diflucan) can also be used if necessary.

It is important to take the full course of antibiotic or antifungal medication as prescribed, even if the symptoms have gone away. Should symptoms recur or persist despite treatment, contact your health care practitioner.

Antibiotic and antifungal medications are effective in eradicating the major infectious causes of vaginal discharge. Both gonorrhea and Chlamydia, when untreated, may progress to more severe infections involving the internal genital organs, known as pelvic inflammatory disease (PID). PID can cause damage to the Fallopian tubes, ovaries, and related structures and lead to ectopic pregnancies, infertility, chronic pelvic pain, and other serious consequences.

 

Treating Normal Discharge

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    Use baby wipes. Wipe away the excess discharge when you go to the bathroom. Try not to get the wipe too far into your vagina; you should only be cleaning the outside (vulva). Use wipes which are unscented and contain as few chemicals as possible.
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    Change your underwear. Changing your underwear 2-3 times a day can help the problem. This will help keep bacteria away from your vagina and will also reduce your discomfort and the smell.
    • Make sure you’re wearing the right kind of underwear, since wearing the wrong kind can even be causing the problem! Wear cotton underwear with good ventilation (meaning those skinny jeans you wear can also be causing the problem).
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    Air yourself out. Try to get as much air exposure as possible. Sleep naked or walk around your house without pants or underwear if you can. The air will help keep your skin from becoming irritated and decreasing opportunities for infection. It can also help treat the problem itself, if your body simply has an imbalance of bacteria, since it will give your body the opportunity to restore itself to normal.
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    Use a pad or pantyliner in extreme cases. Generally you want to avoid these, as usually your body creates the discharge to get rid of something and keeping that something close to your body is not the best idea. However, if you are in a situation where you really need to keep the discharge in check or the discharge is so bad it cannot be controlled, you can use a pad or pantyliner. Try to change it as often as possible.
    • Don’t use douches. Many douches that are bought at the store contain “scents” or soaps, these may make you feel cleaner in the short term, but in the long run will actually make the problem worse. They will disrupt the natural pH of your vagina and cause it to work overtime to get back to its normal state.
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    Try herbal remedies to control your discharge: Herbs are safe and effective remedies to prevent abnormal discharge from your vagina. Many herbal remedies are effective in eradicating the infection of vaginal mucosa. Many of them also have astringent action to reduce the flow of abnormal discharge.
    • Herbs like Pippali are believed to cleanse your body by eliminating infection causing organisms from your body.
    • Herbs like Saraca ashoka, Symplocos racemosa, Cyperus rotundus, Ficus benghalensis, vetiveria zizanioides, Andropogon muricatus and Acacia confusa reduce the vaginal discharge due to their astringent properties.
    • Herbs such as Cimicifuga Racemosa assist in eradication of fungal infection and for reducing inflammation, which is associated with leucorrhoea.

 

Treatment

Once you’ve established the diagnosis, the best source of updated treatment information is the CDC (www.cdc.gov/std/treatment/2006/vaginal-discharge. Accessed April 2, 2008). Treatment regimens are generally different for pregnant and non-pregnant patients.

Bacterial vaginosis. All non-pregnant patients with symptomatic BV require treatment to relieve symptoms and prevent post-abortion or post-hysterectomy complications (Table 2). Suggested medications include topical and oral metronidazole or topical clindamycin. Symptomatic pregnant patients should be treated to prevent adverse pregnancy outcomes (Table 3). Clinicians who screen asymptomatic patients should do so at the first prenatal visit and start any needed therapy immediately. Only systemic metronidazole or clindamycin is recommended; no topical agents are included in the treatment regimen for pregnant patients. Treatment of sex partners does not appear to affect pregnancy outcomes and is not recommended.

Vulvovaginal candidiasis (VVC). Treatment of uncomplicated VVC in nonpregnant patients centers around topical azoles; fluconazole is the only oral agent recommended (Table 4). Intravaginal preparations of some topical azoles are available OTC. Patients whose symptoms are unrelieved by OTC products or who suffer a recurrence within two months of discontinuing treatment should be evaluated by a clinician. Sex partners do not require treatment unless the woman suffers recurrent bouts. Frequent recurrences are generally treated with azoles as well, but for a longer duration. Only topical azoles are recommended during pregnancy.

Summary

If a patient complains of vaginal symptoms, do the appropriate testing, i.e., cultures, microscopy, etc.; don’t treat over the phone; and prescribe the most appropriate medication while taking into consideration the patient’s status of compliance. For example, a seven-day vaginal treatment is not the best option for patients with a history of noncompliance.

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