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Vaginitis

  • Inflammation of the vagina that develops due to a wide range of causes
  • Causes include yeast or bacterial infections, STIs, or natural hormone fluctuations
  • Treatments include antibiotics, antifungals, and some hormone treatments
  • Involves Pathology, Gynecological Pathology, Cytopathology

Overview

As any woman knows, when something causes the vaginal area to feel inflamed, everyday actions like peeing or sitting can be irritating at best and painful at worst. That inflammation, which can develop from very different causes, is called vaginitis.

“Different types of vaginitis may share symptoms of vaginal itching, discomfort, and often associated vaginal discharge,” says Yale Medicine pathologist Angelique Levi, MD.

The symptoms of vaginitis might be limited to the vagina—the muscular canal that connects the uterus to the outside of the body—but they can also affect the external parts surrounding it, called the vulva.

Inside a healthy vagina, an intricate community of bacterial and fungal microbes carry out vital tasks, like keeping the area acidic (a low pH level) enough to ward off infections and producing small amounts of discharge, which keeps the vagina clean. If the delicate balance of these microbial populations is disrupted, the area can turn into a breeding ground for “bad” bacteria or fungus. Another form of vaginitis can be the result of hormonal changes. As a woman’s estrogen levels fluctuate throughout her life, lower levels can lead to vaginal irritation and inflammation.

Given the complex origins of vaginitis, it’s important to seek medical care at the earliest signs of swelling and discomfort.

At Yale Medicine, our specialists take time to identify the specific cause of vaginitis so that the most targeted treatment approach can be found. 

What are the causes, symptoms, and treatments of different types of vaginitis?

The different types of vaginitis can be separated into two categories: infectious and noninfectious. Infectious types mean that the cause can be traced to bacteria, fungi, or a sexually transmitted infection. Noninfectious causes of vaginitis include decreased levels of the hormone estrogen or exposure to irritating chemicals or habits. 

Infectious vaginitis types:

  • Yeast infections. This common ailment for women is also one of the most frequent causes of vaginitis. Yeast infections develop when a certain species of fungus (Candida albicans is the most common type) that is always present in the vagina, gains an edge and outnumbers healthy, friendly bacteria. The primary symptom is a thick, odorless white discharge that looks like cottage cheese. Infections may cause severe itching. Most yeast infections resolve quickly after a treatment with antifungal medication in the form of a cream or pill. Women can be more susceptible to yeast infections when they are pregnant, diabetic, have a weakened immune system, or are taking antibiotics. 

  • Bacterial vaginosis (BV). Bacterial vaginosis is responsible for up to half of all vaginitis cases in the U.S. It is trigged by an overgrowth of “bad” bacteria in the vagina. (BV is not a sexually transmitted infection.) The vagina naturally has high levels of good bacteria mostly made up of a species called Lactobacillus. These bacteria help maintain an acidic environment in the vagina to ward off infections. Different kinds of situations, like pregnancy, having new or multiple sexual partners, or douching and using perfumed soap, can interfere with the delicate balance, allowing bad bacteria to multiply. Signs of bacterial vaginosis include a white, gray or green discharge, itchiness, burning, and a strong, fish-like odor. Sometimes women can have this infection without symptoms, and in some cases the condition may resolve on its own. Depending on the severity of the infection, your doctor may prescribe antibiotics. 

  • Trichomoniasis . Trichomoniasis (sometimes called “trich”) is a sexually transmitted infection that can cause vaginitis. Both sexual partners are infected through sexual contact. This infection is caused by a parasite invisible to the naked eye called Trichomonas vaginalis. While the infection can cause inflammation, about 70% of infected women and men do not show any signs. If a woman does experience symptoms, these can include a vaginal discharge with a fish-like odor. Trichomoniasis is curable with antibiotics and both partners need to be treated. Men with trichomoniasis might experience penile discharge, redness and discomfort. Sexual partners should wait at least 7 to 10 days after finishing the antibiotic before having sex again, according to the Centers for Disease Control and Prevention (CDC). 

Noninfectious vaginitis types:

  • Atrophic vaginitis . At different stages in life, such as during pregnancy or while breastfeeding, a woman will have fluctuations in her levels of the hormone estrogen. A decrease in estrogen naturally happens during menopause—the stage of a woman’s life when she stops having menstrual cycles—and continues during post menopause, when estrogen levels stay permanently low. Estrogen helps keep the vaginal walls healthy and lubricated. As the hormone drops, the tissue gets drier and thinner. Signs of atrophic vaginitis usually develop slowly over time and include pain during sex, vaginal dryness and burning during urination. Vaginal moisturizers and lubricants can help lesson some of these symptoms. Depending on the severity, your doctor may prescribe low-dose estrogen. This can be taken in the form of creams, an oral pill, a skin patch, or a pill inserted into directly into vagina. 

  • Noninfectious vaginitis.This is caused by allergic reaction to a soap or product, like those used for douching. Doctors do not recommend douching—washing the inside of the vagina with water and soap—because it is linked to an increased risk for vaginal infections and sexually transmitted infections (STIs). Mild soap and water is all you need for cleaning the vaginal area. 

How is vaginitis diagnosed?

Your doctor will take down a detailed medical history, conduct an exam, and send a sample of vaginal discharge for lab testing to get an accurate diagnosis. Treatments options vary depending on the cause of the infection or irritation. Antibiotics, as well as anti-fungal creams and pills, can quickly resolve some forms of vaginitis. In other cases, hormone pills may be needed. Your doctor may also recommend modifying vaginal hygiene habits so that potential irritants like fragrances, douching, or deodorants are taken out of the picture. 

Pathologists can diagnose the causes of vaginitis, both non-infectious and infectious, by visually examining a Pap Test slide under the microscope. The morphologic differences in the size, shape and staining pattern of cervicovaginal cells allow a well-trained pathologist to identify atrophy. A background of acute or chronic inflammatory cells will signify an inflammatory component. These are the hallmarks of noninfectious or atrophic vaginitis. Additionally, pathologists can identify infectious causes of vaginitis by examining a Pap test. Organisms that may be identified visually in a Pap test include fungal forms consistent with Candida species (cause of yeast vaginitis), Trichomonas vaginalis (cause of trichomoniasis), and an abundance or overgrowth of abnormal bacteria (cause of Bacterial Vaginosis). 

At Yale Medicine, we offer the newest technology to diagnose infectious vaginitis using molecular techniques, both by DNA probe (BD Affirm) and a PCR amplified molecular panel (BD MAX). Clinical providers receive special kits with collection swabs provided by pathologists to sample vaginal mucosa. In the laboratory, a molecular vaginitis panel is performed to simultaneously detect and differentiate the three most common infectious causes of vaginitis noted above. Overall, the advantages of molecular testing are fast results, as well as enhanced sensitivity and specificity for the commonest causes of infectious vaginitis with superior detection of co-infections. Species specific identification, in some cases, may improve potential treatment choices and shorten treatment length. 

In pregnant women, symptomatic infectious vaginitis/vaginosis has been associated with premature deliveries and low birth weight babies. With the growing evidence linking vaginitis to pregnancy complications, accurate and timely diagnosis and treatment are more critical than ever. “With the molecular vaginitis panel, we can confidently detect the relevant infectious organism or organisms in less than one day, which allows for accurate diagnosis, specific treatment, and prompt symptom relief for our patients,” says Dr. Levi.