Dr Jacquie Grassie and Annelize Steyn
Your daily tasks include shopping lists, getting the kids to the dentist, baking a custard pie for the church bazaar and teaching your mother in law how to use Instagram. You’re also writing a speech for your youngest, preparing a presentation and struggling to establish a herb garden.
The last thing you have time for is to focus on your vaginal flora! Fortunately this is one of those things that tend to look after themselves. The body usually maintains a fine balance, and under normal circumstances you don’t have to worry about what’s going on “down there”.
A healthy vagina has a number of processes that inhibit the growth of potential “enemies” by creating lactic acid and hydrogen peroxide (lactic acid maintains the right environment for beneficial bacteria while hydrogen peroxide kills harmful bacteria). Balanced vaginal flora helps to inhibit bacterial and yeast infections and is essential for good vaginal health.
If your flora is normal, you don’t have much to worry about, and although you don’t have to be actively involved in maintaining healthy vaginal flora, there are certain things that can upset the applecart.
There are many factors that can affect the delicate balance in the vagina, like when you are sick or stressed (it doesn’t help when people tell you not to stress), when you use certain medications, and when you wear those tight jeans (after a serious diet). Ditto when you try a fragrant new body wash, indulge in a few “quickies” (involving a lot of friction), or give birth.
All the above can easily disrupt your normal vaginal flora, and when there are too few good bacteria or too many “bad” bacteria or yeast cells, you are in trouble. When your vaginal bacteria are out of kilter, the “good” bacteria become weak, less lactic acid is produced and the pH of the vagina changes.
This means that the harmful bacteria are able to get a foothold, which often leads to a discharge (normal, vaginal secretions are white), strange smells, itching, a burning sensation when you urinate, swelling, irritation, sensitivity and pain.
Your body may succeed in fighting the infection and restoring the natural balance, or you might need help in the form of medication, probiotics or a lifestyle change. You can also prevent an imbalance in your vaginal flora by maintaining good hygiene and sticking to the recommendations made by your gynaecologist.
There are also products on the market with ingredients that promote the proliferation of good bacteria to prevent possible infections and encourage recovery if symptoms are already present.
Here are a few conditions that may be caused by an imbalance in your vaginal flora:
“The normal vaginal flora is mainly aerobic with the presence of around six different bacterial options,” says Jacqui Grassie, a gynaecologist from Pretoria. When the vaginal flora becomes disturbed, bacterial vaginosis (BV) may result, an infection that takes over when the vaginal flora changes and the number of lactobacilli decrease as a result of the overgrowth of anaerobic bacteria.
“We usually don’t see the anaerobic organisms in the flora of the average woman.” The flora presumably changes when repeated alkalinisations (higher pH) take place, as in the case of regular sexual contact or douching.”
Jacqui explains that when the level of lactobacilli drops it becomes very difficult for normal flora to regenerate – and it is then when repeated infections become a common occurrence. “BV is associated with risk of infection after a hysterectomy or abnormal pap smears. It can cause serious complications during pregnancy, like premature birth.”
A diagnosis of BV is made:
• If there is a fishy smell with a discharge
• If there is a milky-white or grey, thin vaginal discharge
• If the vaginal pH is higher than 4,5 (usually 4,7 to 5,7)
• By a microbiologist from a vaginal swab
Jacqui explains that medical treatment needs to inhibit the growth of anaerobic organisms, but not that of the lactobacilli. Metronidazole is the treatment of choice and can be applied vaginally in the form of a gel. This gel is available over the counter. Clindamycin can also be used but only on prescription. It is not necessary that your partner also be treated.
Trichomonas vaginitis (TV)
Trichomonas vaginitis (TV) can be caused by disturbed vaginal flora as a result of the sexually transmitted parasite trichomonas vaginalis. This parasite causes an anaerobic vaginal environment and is commonly observed along with BV. It is diagnosed in the case of a severely malodorous vaginal secretion (often in conjunction with an itchy vulva).
A vaginal secretion from the vulva is sometimes seen, and vaginal redness with a red, raised cervix may be observed in serious cases. The pH is usually higher than five and the microbiologist is able to see the parasites. Because it is a sexually transmitted disease, patients also need to be tested for other sexually transmitted diseases like gonorrhoea and chlamydia.
The best treatment for TV is once again oral Metronidazole, but in this case the sexual partner also needs to be treated.
Around 75% of all women will experience at least one episode of vulvovaginal candidiasis (VVC) during the course of their lives. About 45% will have two or more episodes per year. Fortunately the minority of patients will have to cope with chronic candidiasis, Jacqui explains.
Candida is ’n fungal or yeast infection that causes an itch (sometimes there is hypersensitivity when the patient is ill). You are also more susceptible to candida if you are using antibiotics, have diabetes or are pregnant.
A secretion that looks like cottage cheese is quite common and can be thick or watery. Sex involving pain, burning and irritation are further symptoms, as well as a burning sensation when you have finished urinating. Sometimes the vulva is red and swollen. The vaginal pH is usually normal and a microbiologist will be able to see fungal elements.
The treatment of VVC usually involves topical Azole medication. In 80% of cases it will improve symptoms and usually takes two to three days to work. Oral fluconazole (a 150 mg single dose) works well and a low-dose steroid cream (1%) will address the irritation and itching.
A small percentage of patients will develop repeated chronic VVC which is usually more associated with a burning sensation than itching. Cultures and/or biopsy are important when the condition is diagnosed, and patients are treated with Kerzconazole (400mg/d) or Fluconazole (200mg/d), to be used daily until symptoms improve. The patient is then maintained on low-dose treatment (fluconazole 150mg weekly) for six months.
Atrophic vaginitis may develop in older patients experiencing a reduction in oestrogen production. Oestrogen is important for the maintenance of normal vaginal flora. Usually sufferers experience pain during sex and bleeding after sex. Under examination the vagina appears thin and atrophied. This condition is treated with topical oestrogen vaginal cream. Systemic oestrogen cream can prevent recurrence.
Jacqui explains that she often diagnoses patients with vaginitis after they were erroneously treated for a urinary tract infection. It is important to send a patient’s urine for microscopy, culture and sensitivity before treatment is commenced. Because a urinary tract infection can also cause burning and pain patients are often subjected to incorrect treatment.
Normal vaginal flora and good vaginal hygiene are therefore very important to prevent conditions like urinary tract infections and vaginitis. To prevent BV and TV, it is essential that both partners be monogamous. CV can be prevented by wearing suitable cotton underwear, avoiding douching and unnecessary antibiotic treatment, and limiting the use of flavoured bath soaps and foam. The use of oral or vaginal probiotics can also help to prevent candida vaginitis.
Although your “to-do” list may not be that long, bear in mind that there are many things you need to avoid doing to keep your vaginal flora as normal as possible.
*Dr Jacquie Grassie is a gynaecologist & obstetrician in Pretoria and Annelize Steyn is the editor of INTIEM.