Abnormal vaginal discharges are usually caused by vaginal infections, the most common of which include bacterial vaginosis (BV), vulvovaginal candidiasis (thrush) and trichomoniasis (a sexually transmitted infection).
Most common types of vaginal discharges/infections
Bacterial Vaginosis (BV)
Bacterial vaginosis (BV) is also sometimes called anaerobic vaginal discharge, non-specific vaginal discharge or Gardnerella vaginal discharge. BV is one of the most common vaginal infections.
Although the exact causes of BV are unknown, it is caused when the delicate eco-system of the vagina is upset because of the rapid growth of several kinds of bacteria that normally live in the vagina.
Small organisms called Lactobacilli help to keep the pH at the right level, but using antibiotics, soaps and even having sex can leave the vagina more alkaline, thereby encouraging bacterial growth. BV may also be associated with douchingand smoking. Anecdotally, there appears to be a link between BV and times of stress in a woman’s life
While some women with BV may be asymptomatic or don’t have any symptoms, others may present with some distinguishing symptoms such as a thin, off-white, grey vaginal discharge accompanied by a "fishy" or "musty" odour which gets stronger during menstruation, after sex and after washing with soap. The redness and itching that is associated with yeast or thrush infections tends to be absent with BV.
BV can be treated with over the counter topical (vaginal) or oral antibiotics such as metronidazole or clindamycin. On occasion however, it may require long-term or repeat treatments. Many doctors believe metronidazole shouldn't be used during the first three months of pregnancy as its safety has not been established.
During the treatment cycle, it is recommended that you refrain from having sex. In general, it is not necessary to treat male sex partners. BV may occur between women who have sex with other women, in which case both partners need to be treated.
For many women, BV is a nuisance, but for others it can have a serious effect on their reproductive health. If left untreated, BV can lead to abnormal pap smears, further infection and adverse pregnancy outcomes, such as miscarriage, preterm labour and birth as well as postbirth intrauterine infection.
It could also significantly increase a woman’s chance of HIV infection by up to four times and make her more susceptible to other Sexually Transmitted Infections (STIs) such as trichomoniasis and chlamydial cervicitis.
Recurrence of BV is very common and has been reported to be as high as 70% over a period of nine months following initial diagnosis. In this situation, long-term treatment over 6 months using a vaginal preparation has been reported to be effective.
Vulvovaginal candidiasis (also known as yeast infections or thrush)
Vulvovaginal candidiasis (VVC) is caused by a yeast-like fungus. VVC affects females of all ages, especially after puberty.
Candida are organisms that occur naturally in the healthy vagina, rectum and mouth. When the vagina's balance is disturbed, these organisms can multiply and cause infections such as VVC.
This infection is often found in association with certain other conditions including pregnancy, Aids and diabetes. In addition, the use of oral contraceptives, broad-spectrum antibiotics, corticosteroids and immunosuppressive drugs may increase the risk of acquiring this infection.
A distinguishing symptom of VVC is a white vaginal discharge that may have a texture resembling that of cottage cheese. It is usually odourless.This is often accompanied by itching, frequency of urination as well as a burning sensation when passing urine. It may be accompanied by redness and swelling of the vulval area. Tiny cuts or fissures in the skin can also occur. Painful intercourse is also common with this infection.
VVC may be spread by sexual contact. Some antifungal creams (miconazole and clotrimazole) are available over the counter. Other non-prescription products contain antihistamines or topical anaesthetics that mask symptoms and do not treat the underlying problem. Note: some anti-fungal medicines are oil based and may weaken condoms and diaphragms. Newer types of treatment include a single oral dose of fluconazole or itraconazole.
It is advisable to treat sexual partners with an anti-fungal cream which is applied twice daily for one week on the male genitals. Infection in males may be asymptomatic.
Although not serious, VVC can be very annoying, since it is associated with itching which causes discomfort.
Vaginal candidiasis commonly occurs during pregnancy. The infection is usually harmless, but a few cases of infection of the newborn have been reported where an infection had gone untreated during pregnancy. Treatment is with local vaginal suppositories or cream e.g. clotrimazole (such as Canesten). Oral ketoconazole is contra-indicated during pregnancy. If you are pregnant, do not administer any treatment without the advice of your doctor.
Candida hyphae sometimes penetrate under the vaginal epithelial cells. The infection then tends to recur repeatedly during menstruation. To prevent recurrence, vaginal suppositories or cream can be inserted into the vagina a few days before and a few days after menstruation for two to three months. Oral treatment can also be used once a month for a period of 6 months in this situation.
Trichomoniasis is a sexually transmitted infection (STI) caused by the parasite trichomonas vaginalis, which affects both men and women. In women, the most common site of infection is the vagina. The trichomonas vaginalis parasite is not part of the normal vaginal flora.
Trichomoniasis may also be passed between individuals non-sexually, as the parasite can survive in bodily fluids outside the body for a few hours.
Many women and most men never have symptoms and are asymptomatic carriers. When symptoms do occur, they usually appear within four to 20 days of exposure, although symptoms may also appear years later.
A possible distinguishing symptom of trichomoniasis is a yellow-green or grey, thin, foamy and foul-smelling vaginal discharge. Symptoms may worsen during menstruation.
Although symptoms of trichomoniasis in men may disappear within a few weeks without treatment, they can still transmit the disease to their partners.
Given that the disease is sexually transmitted, it is preferable for both partners to receive treatment to eliminate the parasite.
Generally, the treatment for trichomoniasis is metronidazole, which is usually prescribed in one large oral dose or several smaller doses taken over three to seven days. Note: drinking alcohol while taking this drug can cause nausea and vomiting.
Trichomoniasis may increase risk of transmission of HIV so talk to your doctor about getting tested for this and other STIs.
During pregnancy, the trichomonas vaginalis organisms are not transmitted to the foetus or newborn, but there is a possible association with premature rupture of the membranes and preterm labour. Treatment of this infection during pregnancy is highly controversial and should not be undertaken without consulting a specialist.
Recurrences of trichomoniasis may be due to re-infection or relapse. Re-infection can be due to the failure to treat all sexual partners. Recurrences generally require a higher dose of metronidazole and a longer treatment plan. Re-examination after treatment is essential to making sure the disease has been successfully treated.
To prevent re-infection, a condom should be used during sexual intercourse until treatment has been completed. Condoms and diaphragms may help prevent trichomoniasis.
Postmenopausal vaginal discharge
Postmenopausal (atrophic) vaginal discharge is an infection or inflammation of the vagina
caused by lowered oestrogen levels that upset the vagina's normal balance.
After menopause, the vaginal tissues are no longer exposed to oestrogen and may become weakened, dry and thus prone to infection. Tiny tears or cuts may appear in the vaginal wall, causing a blood-tinged discharge.
There may be a bad-smelling vaginal discharge, which is usually thin, whitish or yellowish and sometimes blood-tinged.
Treatment consists of oestrogen replacement therapy either topically, transdermally or orally, and treatment of the secondary infection if present. A water-soluble lubricant may be used if oestrogen cannot be taken.
Other causes may include allergic and irritative factors or other sexually transmitted infections. Non-infectious allergic symptoms can be caused by chemicals in products such as spermicides, vaginal hygiene products, detergents, fabric softeners and more rarely, latex.
Cervical infections are also often associated with abnormal vaginal discharge, but these infections can be distinguished from true vaginal infections by appropriate tests.
In uninfected women, vaginal discharge may sometimes be present during ovulation and may become so heavy that it raises concern.
Features of vaginal infections
(Source: Adapted from 'Vaginal discharge: A guide for women, iNova pharmaceuticals')
The following factors may increase the likelihood of an abnormal vaginal discharge:
- General poor health, including lack of sleep, poor diet and stress.
- Hot weather, non-ventilating clothing, especially underwear, or any condition that increases genital moisture, warmth and darkness.
- Changes in hormone levels through pregnancy, breast-feeding, menopause, some oral and intramuscular contraceptives and steroid use.
- Alcohol consumption.
- Douching - this can upset the natural vaginal balance, as can other chemically treated products such as "feminine hygiene" sprays.
- Drugs or diseases that lower the body's resistance to infection - women with HIV infection, for example, are more prone to yeast infections.
- Diabetes mellitus or a pre-diabetic condition.
- Unprotected sexual intercourse, especially with multiple partners.
- Sexually transmitted infections (STIs).
- Infection elsewhere in the body.
- Antibiotics can kill beneficial vaginal bacteria.
- Antibacterial soaps and topical antimicrobial agents.
- Over-the-counter medications improperly used.
- High carbohydrate intake, especially sugars and alcohol - may stimulate yeast infection.
If you have symptoms of an abnormal vaginal discharge, a correct diagnosis is needed before the condition can be treated.
The pharmacy is your first, and most accessible, port of call. Speak to your pharmacist or clinic sister about your concerns and treatment options and look out for the new pink self-diagnosis toolkit available in pharmacies. A word of caution: if you are pregnant or have a vaginal discharge accompanied by pain, please contact your doctor immediately.
The complications of an untreated vaginal discharge may be serious. Be sure to see your doctor if you experience any of the following symptoms:
- You are pregnant.
- You have a yellow or green vaginal discharge.
- Symptoms worsen or don’t abate despite treatment.
- OTC medication doesn’t work.
- After treatment, symptoms recur.
- You have recurrent vaginal discharge.
- Unusual vaginal bleeding or swelling develops.
- You have been exposed to an STI.
- You have had unprotected intercourse with new partners.
- Vaginal discharge is accompanied with pain.
- If you use a cream or suppository, use a small sanitary pad to protect clothing.
- After treatment, you may want to keep a refill of the medication so you can begin treatment quickly if the condition recurs.
- Keep creams or suppositories in the refrigerator if indicated.
- Check with your doctor about any other medication you may be taking. Some medications may make your vagina more susceptible to infection.
- If urination causes burning, pour a cup of warm water over the genital area while you urinate. This dilutes the acidity of the urine.
- Avoid overexertion, heat and excessive sweating.
- Abstain from sex until after treatment, or use condoms.
- When allergy causes vaginal discharge, avoiding the allergic agent may end the irritation.
Reviewed by Dr Sumayya Ebrahim, gynaecologist in private practice at the Park Lan Clinic, Johannesburg, April, 2010