Chronic Vaginal Discharge -- Management considerations

Vaginal discharge that is difficult to treat: Management consdierations

 Physiological discharge

It is normal and healthy for women of reproductive age to have some degree of vaginal

discharge. The quantity and type of cervical mucus changes during the menstrual cycle as a

result of hormonal fluctuations. Prior to ovulation, estrogen levels increase, altering cervical

mucus from non-fertile (thick and sticky) to fertile (clearer, wetter, stretchy and slippery). After

ovulation, estrogen levels fall and progesterone levels increase; cervical mucus becomes

thick, sticky and hostile to sperm. The vagina is colonised with commensal bacteria (normal vaginal flora). Rising estrogen levels at puberty lead to colonisation with lactobacilli which metabolise glycogen in the vaginal epithelium to produce lactic acid. Thus the vaginal environment is acidic and normally has a pH≤4.5. Other commensal bacteria include anaerobes, diphtheroids, coagulase-negative staphylococci and α-hα-haemolytic streptococci. Some commensal organisms can cause a

change in discharge if they ‘overgrow’. These include Candida albicans, Staphylococcus

aureus and Group B streptococcus.

Commonest Causes of Altered Vaginal Discharge in Women of Reproductive Age?

There are three common causes of altered vaginal discharge in women of reproductive age:

1.      Infective (non-sexually transmitted)

a.      Bacterial vaginosis

b.       Candida

2.      Infective (sexually transmitted)

a.      Chlamydia trachomatis

b.      Neisseria gonorrhoeae

c.      Trichomonas vaginalis

d.      Herpes simplex virus

3.Non-infective

• Cervical polyps and ectropion
• Genital tract malignancy
• Allergic reactions.

4. Non-sexually transmitted infections

Bacterial vaginosis

BV is the commonest cause of abnormal vaginal discharge in women of reproductive age.2

Reported prevalence varies and may be influenced by behavioural and/or

sociodemographic factors.3–5 It can occur and remit spontaneously and is characterised by

an overgrowth of mixed anaerobic organisms that replace normal lactobacilli, leading to an

increase in vaginal pH (>4.5).  Gardnerella vaginalis is commonly found in wommen with BV but the presence of Gardnerella alone is insufficient to constitute a diagnosis of BV because it is a commensal organism in 30–40% of asymptomatic women. Other organisms associated with BV include Prevotella species, Mycoplasma hominis and Mobiluncus species.

 BV is considered to be ‘sexually associated’ rather than truly ‘sexually transmitted’. There is some evidence that consistent condom use may help to reduce BV prevalence,7,14–16 although one study

suggested this may only be in women who were BV-negative at baseline.15

Vulvovaginal candidiasis (VVC)

VVC is common among women of reproductive age. It is caused by overgrowth of yeasts;

C. albicans, in 70–90% of cases, with non-albicans species such as C. glabrata in the

remainder. The presence of candida in the vulvovaginal area does not necessarily require

treatment, unless symptomatic, as between 10% and 20% of women will have vulvovaginal

colonisation.

Candidiasis occurs most commonly when the vagina is exposed to estrogen, therefore it is more common during the reproductive years and during pregnancy. An episode of VVC is

often precipitated by use of antibiotics.Immunocompromised women20,21and women with

diabetes are predisposed to candidiasis. VVC does not appear to be associated with

tampons, sanitary towels or panty liners when they are used appropriately.24

As Vulvovaginal candida can be found in non-sexually active individuals, it is not classed as an STI.

3.2 Sexually transmitted infections

Chlamydia trachomatis

Chlamydia trachomatis, the most common bacterial STI in the UK, is usually asymptomatic in

women (approximately 70%). However, women may present with vaginal discharge due to

cervicitis, abnormal bleeding (postcoital or intermenstrual) due to cervicitis or endometritis,

lower abdominal pain, dyspareunia or dysuria.

Neisseria gonorrhoeae

Gonorrhoea is an STI caused by Neisseria gonorrhoeae. Up to 50% of women will be

asymptomatic. Common symptoms may include increased or altered vaginal discharge and

lower abdominal pain. It can also be a rare cause of heavy menstrual, postcoital or

intermenstrual bleeding due to cervicitis or endometritis.25

Trichomonas vaginalis

TV is a flagellated protozoan that causes vaginitis. Women with TV commonly complain of

vaginal discharge and dysuria (due to urethral infection).

TV is always sexually transmitted and is a rarer condition than BV or VVC.

Herpes simplex

Women with cervicitis due to herpes simplex virus infection may occasionally present with

vaginal discharge.

 Other causes of vaginal discharge

Other causes of vaginal discharge include foreign bodies (e.g. retained tampons or

condoms), cervical ectopy or polyps, genital tract malignancy, fistulae and allergic reactions.

Exclusion of infective and other causes can help confirm that a vaginal discharge is

physiological.

There is some association between methods of contraception and vaginal discharge. Women complaining of vaginal discharge should be asked about current and past contraception.

Douching is the process of intravaginal cleaning with a liquid solution. Some women use the

practice of douching as part of their general hygiene or cultural practice. Data suggest that

douching changes vaginal flora and may predispose women to BV, although not all

studies have reported this finding. Overall, the evidence suggests that douching should be

discouraged as there are no proven health benefits.

.

Women with cervical ectropion may complain of increased physiological discharge. Ectopy is a

normal finding in women of reproductive age but treatments such as acidic gel, silver nitrate

cauterisation, laser or cold coagulation are occasionally used in a gynaecology setting for

symptomatic relief of vaginal discharge or postcoital bleeding. There is a lack of robust

evidence for the effectiveness of these treatments in reducing vaginal discharge. Cervical

pathology must be excluded prior to treatment, and women’s should be informed of potential

risks of treatment and the fact that discharge symptoms may initially worsen before there is

any improvement. evidence as to whether the use of hormonal contraception increases the risk of VVC.

 One study has suggested that the progestogen-only injectable may reduce a woman’s susceptibility

to recurrent VVC, possibly because of its anovulatory effect and relative hypoestrogenism.

Women using Combined hormonal contraception who have recurrent VVC may wish to consider alternative contraception but there is a lack of evidence to show whether there is any benefit from switching to a lower dose combined preparation or a progestogen-only method, other than the injectable.

The Cu-IUD has been identified as a possible risk factor for acute or recurrent VVC, but there

is no consistent evidence of an association. There is some evidence to demonstrate that

yeasts adhere to IUDs and the combined vaginal ring (CVR). Combined vaginal ring users have been

reported as experiencing more vaginal irritation and discharge compared with combined pill

users. However, a study of the effect of CVR use on vaginal flora showed no increase in

numbers of inflammatory cells or pathogenic bacteria.

Although cervical cytology slides from levonorgestrel-releasing intrauterine system (LNG-IUS)

users have shown increased presence of candida with time from insertion, rates of

symptomatic infection did not change significantly.

Bacterial vaginosis

Oral combined contraception and condoms have been associated with a reduced risk of

BV, whilst BV is more common in users of the Cu-IUD. The association between BV and

use of the LNG-IUS is unclear. The progestogen-only implant and injectable may be

associated with a decreased risk of BV.Women using CHC who experience recurrent VVC may wish to consider switching to an alternative method of contraception. Women with a Cu-IUD who experience recurrent BV may wish to consider switching to an alternative method of contraception.

8 Personal Hygiene and Vaginal Discharge

Personal hygiene measures can be advised for women who are prone to vaginal discharge

and/or pruritis (e.g. regular changing of sanitary protection, avoidance of douching and of

potentially irritant chemicals in toiletries, antiseptics, wipes, so-called ‘feminine hygiene’

products, washing powders, fabric dyes, and so on). RCOG guidance contains patient

information on general care of the vulval skin, including use of emollients and soap substitutes

which prevent dryness and loss of the skin’s natural barrier functions.Women experiencing vaginal discharge can be advised to avoid douching and local irritants as part of general management.

Health professionals should be aware that the most common causes of altered vaginal

discharge are physiological, BV and candida, but STIs and non-infective causes must be

considered. Table 1 Summary of signs and symptoms of infective causes of vaginal discharge

Sign/symptom Bacterial vaginosis Candida Trichomoniasis

Discharge Thin Thick white Scanty to profuse

Odour Offensive/fishy Non-offensive Offensive

Itch None Vulval itch Vulval itch

Other possible symptoms Soreness Dysuria

Superficial dyspareunia Lower abdominal pain

Dysuria

Visible signs Discharge coating the Normal findings Frothy yellow discharge

vagina and vestibule or Vulvitis

Vaginitis

No vulval inflammation Vulval erythema Cervicitis

Oedema ‘Strawberry cervix’ (ectocervix

Fissuring sometimes resembles the surface of

Satellite lesions a strawberry)

Point-of-care test: vaginal pH >4.5 ≤4.5 >4.5