Vaginitis and Vulvovaginitis

DESCRIPTION
Vaginitis is an infection of the vaginal tract that causes inflammation of the vaginal lining. In ulvovaginitis, the inflammation extends to the vulva, the external genital area, which includes the pubic mound, labia, clitoris, and opening of the urethra, as well as the vaginal tract. Although vaginitis can be caused by a sexually transmitted infectious micro-organism, it is more typically due to a disturbance in the delicate ecology of the vagina that allows organisms normally found in a healthy vagina to overgrow and produce an infection. Symptoms vary somewhat depending upon the causative infectious agent, but all involve increased volume of vaginal secretions; abnormal colour, consistency, or odour of vaginal secretions; vaginal and vulval itching, burning or irritation; and painful urination or pain with intercourse.

Almost all women experience vaginitis at some time during their lives. One of the most common reasons women seek medical attention, vaginitis accounts for approximately 7% of all visits to gynecologists. Vaginal infections are six times more common than urinary tract infections, and painful urination is much more likely to indicate a vaginal rather than a urinary tract infection. Since the vagina can become a reservoir of infectious bacteria, recurrent urinary infections are often the result of chronic vaginal infection.

Although over-the-counter medications can be purchased to treat vaginitis, it is important to consult a physician and get a precise diagnosis for several reasons. (1) There are different kinds of vaginitis, and, to be truly effective, treatment should be targeted to the specific microbial cause and to the underlying causes that allowed it to multiply and produce this vaginal infection. (2) Vaginitis may be a symptom of a more serious underlying problem, such as a sexually transmitted disease or cervicitis – a chronic inflammation of the cervix, which if untreated, may progress to cervical dysplasia. (3) If not properly treated, the infection may travel up the vagina to deeper tissues and lead to pelvic inflammatory disease – a serious condition that can result in infertility because of scarring of the fallopian tubes.

 
FREQUENT SIGNS AND SYMPTOMS

Signs and symptoms vary depending upon the causative agent.

• Candida albicans
• Vulval itching, which can be severe, is the key symptom of a vaginal yeast infection
• A thick, curdy, or “cottage cheese” discharge is also common, but a scant discharge or its absence does not rule out Candida infection
• Pelvic examination will reveal adherent white patches with a reddened border
• No odor
• pH < 4.5.
• Trichomonas vaginalis:
• The most frequent symptom of trichomonal infection is a frothy, malodorous (may smell fishy), greenish-yellow vaginal discharge
• Discharge is accompanied by itching and burning
• Pelvic examination may show reddened bumps on the cervix or vaginal lining
• pH > 5.0.

 

• Neisseria gonorrhoeae:
• Although gonorrhea may be present with no symptoms, during reproductive years, the primary symptom of gonorrhea is severe infection of the cervix with painful, bloody, pus-filled discharge
• No odor
• Pelvic examination will show cervical discharge; may have pelvic tenderness
• pH < 4.5.

 

• Chlamydia trachomatis:
• Chlamydia infects 5–10% of sexually active women, but is usually without symptoms until other infections develop (e.g., in the cervix, fallopian tubes, or urethra), and then may produce symptoms of pelvic inflammatory disease (PID)
• No discharge or odor
• Pelvic examination may show signs of PID
• pH < 4.5.

 

• Nonspecific vaginitis (NSV):
• Key symptoms are the odor and discharge
• The odor is fishy, foul or rotten, and the discharge is nonirritating, grey in color, usually of even consistency, and occasionally frothy, or thick and pasty
• Pelvic examination shows no unusual symptoms
• pH > 4.5.

 

• Herpes:
• Primary symptom is small genital blisters (vesicles) or ulcers
• No discharge or odor
• Pelvic examination shows small, multiple vesicles or ulcers on the cervix or labia
• pH < 4.5.

CAUSES

Approximately 90% of vulvovaginitis is associated with one of three organisms: Trichomonas vaginalis, Candida albicans, or Gardnerella vaginalis.

• Trichomonas vaginalis: a sexually transmitted single-celled organism, Trichomonas does not invade tissues and rarely causes serious complications.
• Candida albicans: vaginal infection with Candida, a yeast that is a normal inhabitant of the gastrointestinal tract, has increased dramatically over the last 40 years, largely because of the frequent use of antibiotics. Antibiotics destroy friendly flora in both the gastrointestinal tract and vagina, allowing Candida to multiply aggressively and encouraging its transmission from the intestinal tract to the vagina. Allergies, which also damage the lining of the gastrointestinal tract, have been reported to cause recurrent Candida overgrowth and vaginal infection, which resolves when the allergies are treated.
• Nonspecific vaginitis (NSV): a category defined as “vaginitis not due to Trichomonas, gonorrhea, or Candida”, NSV is identified by its primary symptoms – a non-irritating grey discharge with a fishy, foul odour. The odour is caused by the breakdown of proteins by bacteria and worsens as the pH level, which is elevated to 5.0–5.5 in most cases, rises:
• The organism most frequently cited as responsible for NSV is Gardnerella vaginalis, which is found in 95% of women with NSV, but is also found in 40% of women without vaginitis.
• Although Gardnerella prospers under the conditions of NSV, growing evidence suggests that anerobic bacteria are NSV’s primary cause:
• Gardnerella lacks the enzymes to produce the amines characteristic of NSV, and the antibiotic most effective against NSV is more active against anerobes than Gardnerella.
• Neisseria gonorrhoeae: a sexually transmitted organism, N. gonorrhoeae is responsible for less than 4% of vaginitis cases:
• Gonorrhea is more common among young girls because the vaginal epithelium is thinner before puberty.
• Gonorrhea, either alone or in combination with other organisms, is cultured in 40–60% of cases of pelvic inflammatory disease, a serious infection that is a major cause of infertility.
• Herpes simplex: a sexually transmitted organism, herpes simplex virus, is the most common cause of painful genital ulcers, which may occur on the labia or cervix. However, the key symptoms of other forms of vaginitis – itching, odour and increased vaginal discharge – are not present in herpes simplex infection (for additional information, see the web article on Herpes simplex).
• Chlamydia trachomatis: a parasite that lives within human cells, Chlamydia rarely causes vaginitis on its own, but is frequently found in association with other causes, such as Candida albicans. Identifying and properly treating Chlamydia is extremely important:
• Chlamydia is frequently found in cultures of women with pelvic inflammatory disease and is a major cause of infertility because of scarring of the fallopian tubes.
• During pregnancy, chlamydial infection increases the risk of premature delivery and infant death.
• If a healthy baby is born to a woman with a chlamydial infection, the child has a 50% risk of developing chlamydial infection of the eyes and a 10% chance of contracting pneumonia.

RISK INCREASES WITH

• Antibiotic treatment: antibiotics kill protective friendly organisms in the vagina (particularly Lactobacillus acidophilus).
• Allergies: the ingestion of allergenic proteins results in damage to the intestinal lining. Breeches in the integrity of the intestinal wall allow not only allergens, but also pathogens and other toxins to enter into the general circulation, placing significant stress on the immune defense system.
• High intake of refined carbohydrates, especially sugars and alcohol.
• Hot weather and non-ventilating clothing, particularly pantyhose, that increases moisture, warmth, and darkness – ideal conditions for the growth of infectious organisms.
• Diabetes mellitus: the elevation in blood sugar levels results in a less effective immune response and a more favourable environment for infectious organisms.
• Pregnancy: the sugar (glycogen) content in vaginal tissues increases during pregnancy, providing a more hospitable environment for Candida overgrowth.
• Menstruation: the presence of blood provides a more favourable environment for the growth of some infectious organisms.
• Oral contraceptives: birth control pills contain synthetic oestrogen, the hormone responsible for the building up of the uterine lining each month. A thicker uterine lining results in more menstrual bleeding when the lining is shed.
• Immunosuppression caused by drugs such as steroids or by disease.

PREVENTIVE MEASURES

• Use antibiotics only when truly necessary.
• Identify and eliminate food allergens from the diet.
• Minimize consumption of refined carbohydrates, sugars, and alcohol.
• Consider switching from oral contraceptives to a different form of birth control.
• Practice safe sex: monogamy with a healthy partner or use a latex condom every time for intercourse.
• Avoid tight-fitting, synthetic clothing that traps heat and moisture. Try thigh-high stockings with elasticized tops instead of pantyhose.
• After exercising, get out of hot, sweaty gym clothes promptly. Take at least a quick shower, and towel  and air-dry thoroughly before dressing. Wear cotton underwear and clothing made from natural fabrics or synthetic fabrics that wick away moisture.
• In recurrent cases of vaginitis, consider having sexual partners treated.

Expected outcomes

 
Effective treatment requires proper identification of the cause of vaginitis. After proper evaluation and diagnosis, an effective treatment plan generally produces significant improvement within 1–3 days. However, to ensure full elimination of the infectious organism, it is important to continue with the full course of prescribed treatment even after resolution of signs and symptoms.

 
TREATMENT

• Consult a physician for an accurate diagnosis.
• Avoid sexual activity during treatment to prevent reinfection and to reduce trauma to inflamed tissues. If this is not possible, at least use a condom.

Diet

• Eliminate refined and simple sugars:
• Consuming 75 g (3 oz) of sugar in one sitting in any form (sucrose, honey, fruit juice) depresses white (immune) cell activity by 50% for 1–5 hours.
• Sugar is the chief nutrient for Candida albicans.
• On labels, sugar may be listed as fructose, maltose, dextrose, polydextrose, corn syrup, molasses, sorbitol, maltodextrin, honey, or maple syrup. Fruit juice, which concentrates fruit sugars, should also be avoided.
• Eliminate alcohol:
• Alcohol damages the liver, raises blood sugar levels, and increases intestinal permeability, allowing infectious agents access to the rest of the body.
• Eliminate milk and dairy products:
• Milk’s high content of lactose (milk sugar) promotes Candida overgrowth.
• Milk is one of the most common food allergens.
• Milk may contain trace levels of antibiotics.
• Eliminate mould and yeast-containing foods including alcoholic beverages, cheeses, dried fruits, melons, and peanuts.
• Eliminate all known or suspected food allergens (for more information about how to identify and treat food allergies see the chapter on Food allergy).
• Consume a health-promoting diet rich in whole, unprocessed, preferably organic foods, especially  plant foods (vegetables, whole grains, beans, nuts [especially walnuts], and seeds), and cold-water fish.

Nutritional supplements

• A high-potency multiple vitamin and mineral daily supplement providing all of the known vitamins and minerals. Among those contained in a multiple, the following nutrients are particularly important in vaginal health and should be present in the following amounts:
  Vitamin Amount
  Vitamin A 5,000 IU or beta-carotene: 50,000 IU
  Vitamin B1 (thiamin) 10–100mg
  Vitamin B2 (riboflavin) 10–50mg
  Niacin 10–100mg
  Niacinamide 10–30mg
  Vitamin B6 (pyridoxine) 25–100mg
  Biotin 100–300 ?g
  Pantothenic acid 25–100mg
  Folic acid 400 ?g
  Vitamin B12 400 ?g
  Choline 10–100mg
  Inositol 10–100mg
  Zinc 10–15 mg if zinc picolinate is used; if not, 30–50mg
  Vitamin E 200 IU of mixed tocopherols
  Caution: folic acid supplementation should always be accompanied by vitamin B12 supplementation to prevent folic acid from masking a vitamin B12 deficiency.
  Lactobacillus acidophilus: this desirable bacterium is an integral component of normal vaginal flora and helps prevent the overgrowth of Candida albicans and less desirable bacterial species:
  L. acidophilus promotes vaginal health by (1) producing lactic acid and natural antibiotic substances, and (2) competing with other bacteria and Candida for available glucose (sugar).
  Dosage: an oral dosage of 1–2 billion live organisms q.d., plus douching with an acidophilus-containing solution (discussed below under Topical medicine).

Botanical medicines

• Glycyrrhiza glabra (licorice): licorice is an effective antiviral, and licorice gel, applied topically, has proven quite helpful in reducing the healing time and pain associated with herpes lesions. In addition, licorice  contains isoflavonoids that have been shown effective against Candida:
• Allium sativum(garlic): garlic is antibacterial, antiviral, and antifungal, and has even been shown to be effective against some antibiotic-resistant organisms
• Hydrastis canadensis (goldenseal): goldenseal is a remarkably safe and effective natural antibiotic. Its most active alkaloid constituent, berberine sulfate, exhibits a broad range of antibiotic action against a wide variety of bacteria (including Chlamydia, Trichomonas, and N. gonorrhoeae), fungi (including Candida), and protozoa. Its action against some of these pathogens is actually stronger than that of commonly used antibiotics, but unlike antibiotic drugs, goldenseal does not destroy the protective bacteria (lactobacilli) in our intestines:
• When taken internally, berberine enhances immune function, and when used in douching solutions, it offers symptomatic relief by soothing inflamed mucous membranes.
• Berberine is a more effective antimicrobial agent in an alkaline environment. Alkalinity can be increased by consuming fewer animal products and more plant foods, especially fruits. Although most fruits are acidic, digestion uses up their acid components leaving behind an alkaline residue.

Drug–herb interaction cautions

• Allium sativum (garlic):
• Plus insulin: animal studies suggest insulin dose may require adjusting because of the hypoglycemic effects of whole garlic (in rats) and its constituent allicin (in rabbits)
• Plus warfarin: the anticoagulant activity of warfarin is enhanced as a result of increased fibrinolytic activity and diminished platelet aggregation caused by garlic components allicin, ajoene, trisulfides, and adenosine.
• Glycyrrhiza glabra (licorice):
• Plus digoxin, digitalis: due to a reduction of potassium in the blood, licorice enhances the toxicity of cardiac glycosides. Interaction with these cardiac glycoside drugs could lead to arrhythmias and cardiac arrest.
• Plus stimulant laxatives or diuretics (thiazides, spironolactone or amiloride): licorice should not be used with these drugs because of the additive increase of potassium loss to potentially dangerous levels.

Topical medicine

• Warm sitz baths with Epsom salts may provide quick relief for itching and burning.
• Douches and pessaries (saturated tampons) are effective methods of concentrating therapeutic agents in the vagina. While other agents may also be effective, the following are chosen since their effectiveness is well referenced in the medical literature. Choose one or more of the agents discussed below. Do not use them together; the variety is given to provide alternatives for use in resistant cases.
• Lactobacillus spp.: prepare a solution using a high quality acidophilus supplement or active-culture yogurt (read the label carefully since most commercially available yogurts do not contain live lactobacilli):
• Dissolve enough in 10 ml of water to provide one billion organisms. Use a syringe to douche the solution into the vagina.
• Since lactobacilli are normal vaginal inhabitants, the douche can be retained as long as desired.
• Povidone-iodine (Betadine): used topically as a douche, Betadine is effective against a wide range of organisms linked to vaginal infections, including Trichomonas, Candida, Chlamydia, and nonspecific vaginitis. A study published in 1969 showed Betadine effective against 100% of cases of candidial vaginitis, 80% of Trichomonas, and 93% of combination infections:
• Available at any pharmacy, Betadine has all the advantages of iodine without stinging or staining.
• Caution: avoid excessive use since some iodine will be absorbed into the system and, in sensitive individuals, can cause suppression of thyroid function.
• Boric acid: capsules of boric acid inserted into the vagina have been used to treat vaginitis due to Candida albicans and have been shown to be significantly more effective than nystatin and creams containing the antifungal drugs miconazole, clotrimazole, or butaconazole:
• In a recent study of 92 women with chronic vaginal yeast infection, patients who used boric acid not only eliminated their vaginal infection, but a microscopic examination of their vaginal swabs also revealed normal vaginal cells.
• No patient who received antifungal drugs had a normal microscopic examination; all demonstrated continued presence of yeast, damaged cells lining the vagina, or some other abnormality.
• Caution: although side effects from boric acid use are quite rare, if boric acid leaks out of the vagina, it may irritate the labia. If this occurs, reduce the amount of boric acid used or discontinue use.

ICIM Medics Approach

If you feel that this article relates to you and you suffer from Vaginitis then please make an appointment to see one of ICIM Medics Natural Medical Practitioners.

Some tests may be prescribed depending upon your individual case, as many vaginal infections stem from gastrointestinal imbalances, often stool analysis may be recommended. The results from these can be used by one of our Natural Medical Practitioners who will help you with your individualised treatment plan. This may include dietary, nutritional and/or botanical advice.

This article is not meant to be used for treatment but for information purposes only. If you feel that this approach is appropriate for you please contact ICIM Medics on 045 844 819 or www.icim.ie e-mail : info@icim.ie  Appointments can be arranged for you.

Tags: Candida Albicans, Chlamydia Trachomatis, Herpes, Neisseria Gonorrhoeae, Non Specific Vaginitis, Vaginitis and Vulvovaginitis