Vaginitis

Symptoms and Causes

What are the causes of vaginitis?

Billions of beneficial bacteria inhabit the human body. They appear in particularly high concentrations in certain areas, such as the gastrointestinal system and the vagina. When the bacterial balance in the vagina is thrown off–which can happen for a variety of reasons–the result is that one strain of bacteria or fungus dominates, thereby causing an infection.

What are the symptoms of bacteria-caused vaginitis (BV)?

When a bacterial infection is the cause of vaginitis, the diagnosis is termed “bacterial vaginosis” (BV). No one knows exactly why some women are more susceptible than others to the bacterial imbalance that leads to BV, but it is extremely common–in fact, BV is the single most common type of vaginitis.

BV triggers include douching and vaginal sprays, washing with harsh soap, and having sex without a condom, particularly with a new partner.

Symptoms are typically a fishy odor, thin discharge, and itching/irritation.  

Is this form of vaginitis an STD? Is it contagious?

It’s important to note that BV is not an STD and is not transmitted from one partner to another. It’s simply the result of a disruption of the bacterial balance in the vagina, which can happen when partners and/or sex toys introduce a different proportion of bacteria.

Can sperm affect BV?

First, and importantly, sperm do not transmit BV. When bacteria from one person’s innate system is shared with another person during sex, the result can be the disruption of the recipient’s natural bacterial balance. But the bacteria that’s introduced from one person to another is on the skin (or an object), rather than in semen.

Seminal fluid can, however, change vaginal pH balance, thereby contributing another risk factor for the development of BV. And when semen comes into contact with vaginal fluid that is already infected with BV, it can release a fishy odor (this may give the sense that sperm is causing an infection, even though the infection is already present).

Women who struggle with BV often find consistent condom use to be helpful. In addition to preventing contact with semen, condoms act as a barrier between the exchange of skin bacteria (and viruses).

What are the symptoms of fungal vaginitis (yeast infections)?

When fungus (most often the candida strain) is to blame for vaginitis, it is called a yeast infection. Like BV, yeast infections are extremely common. Fungus thrives in darkness and moisture, so a typical way to develop a yeast infection would be to sit in a wet bathing suit for a while after swimming, or to not change clothing promptly after exercise.

Another common culprit in the development of yeast is antibiotic use. Antibiotics are effective in the treatment of bacterial infections because they kill bacteria. But antibiotics kill “good” bacteria along with the “bad” bacteria they are intended to treat. When the bacterial balance in the vagina is disrupted in this way, fungus can overgrow, thereby leading to a yeast infection.

Symptoms of yeast infections include intense itching, thick discharge (white, clumpy, sometimes blood-tinged), external vaginal swelling, and small cuts (fissures) on labia.

What about the sexually transmitted diseases that cause vaginitis?

Vaginitis can also be caused by infection with microbes that are sexually transmitted–namely, gonorrhea, chlamydia, and trichomonas.

Symptoms of gonorrhea and chlamydia include discharge (sometimes malodorous), urinary discomfort, pelvic pain, and bleeding after sex. Symptoms of trichomonas involve itching/irritation, thin discharge (usually foul-smelling), and spotting.

Are there any other types of vaginitis?

Sometimes, vaginitis arises without an infectious cause. Declining estrogen levels during and after menopause can lead to a type of vaginal inflammation known as atrophic vaginitis. As estrogen levels drop, the natural lubrication of the vagina decreases, resulting in dryness and thinning of the skin.

These changes can cause discomfort, itching, and sometimes pain with urination and/or sex. Symptoms of atrophic vaginitis are itching/irritation, urinary discomfort, and pain with intercourse.

Diagnosis and Treatment

What’s the typical course of BV or yeast infection?

BV and yeast infections can be extremely bothersome and uncomfortable, but they are generally not dangerous (though there is some evidence to suggest that the presence of BV can increase the risk of acquiring other STDs).

Can yeast or BV go away on their own without antifungals or antibiotics?

Some women find that early, mild symptoms of yeast or BV resolve during menstruation. It’s thought that vaginal bleeding may help to reset the healthy bacterial milieu of the vagina. For significant symptoms, medical treatment is warranted and is generally straightforward.

How is vaginitis diagnosed?

Because vaginitis is associated with some classic symptoms, it can often be diagnosed without lab testing. A fishy odor is a telltale sign of BV. Thick, clumpy, white discharge with itching is almost always yeast.

For women who are familiar with these symptoms because they’ve experienced them before, treatment can be straightforward and may not require a physical exam.

For someone dealing with her first episode of vaginitis, or who may have other factors to consider (e.g., pregnant, or possibly exposed to an STI), it’s a good idea to check in with a healthcare professional.

What tests are used for vaginitis?

There are a few tests available for a definitive diagnosis of vaginitis. In-office testing of vaginal discharge with saline, potassium hydroxide, litmus paper, and a microscope can indicate whether a vaginal infection is due to bacteria, yeast, or trichomonas. Tests processed at a lab are based on vaginal fluid cultures, collected by swab. STI testing can also be performed through swab collection, and urine testing is an option as well.

Some lab tests can provide information with a precise level of detail, such as the type of yeast causing an infection. This may be helpful in the case of an individual experiencing recurrent yeast infections that do not improve with traditional treatment.

Non-infectious vaginitis, such as atrophic vaginitis, can be diagnosed without a lab test. If an individual is near menopause or has already experienced it, and is struggling with vaginal irritation without discharge, a common explanation is declining estrogen. A vaginal examination can sometimes be helpful in confirming the diagnosis, but is not always necessary.

Which antibiotics treat BV and how is it diagnosed?

Since BV is a bacterial infection, it is treated with antibiotics. The medication most commonly prescribed is metronidazole, which can be taken orally in pill form, or can be inserted into the vagina as a gel. When taken as a pill, alcohol must be avoided for the duration of the treatment, up to 24 hours after the last pill. Clindamycin is an alternative antibiotic, also available in both pill and gel form. The course of antibiotics for the treatment of bacterial vaginosis is usually about one week.

How are yeast infections diagnosed and treated?

Yeast infections are treated with antifungal medication. Similar to BV, a yeast infection can be treated orally (with fluconazole–usually one pill taken just once), or with a vaginal cream (often miconazole or clotrimazole, inserted nightly for one week).

How are the STDs that lead to vaginitis diagnosed and treated?

These infections are typically diagnosed by lab testing (urine or a vaginal swab test) and require antibiotics for treatment. Gonorrhea, chlamydia, and trichomonas require treatment with antibiotics.

It’s important that these infections be properly diagnosed by a healthcare provider. And it’s crucial for sexual partners to receive prompt treatment so that these infections are not passed back and forth between partners and/or to other partners.

How is atrophic vaginitis diagnosed and treated?

The treatment of atrophic vaginitis depends on the severity of symptoms. For women who only experience discomfort during sex, a water-based lubricant may be sufficient to use as needed.

In addition, a vaginal moisturizer may be applied two-to-three nights per week. If these over-the-counter options are inadequate, there are a number of topical estrogen preparations available by prescription, including vaginal tablets and creams.

Recurrence and Prevention

Why does vaginitis come back sometimes?

For some individuals, BV and yeast infections have a tendency to recur. It’s unclear exactly why this happens to certain women more frequently than others. If signs and symptoms of an infection recur within a few weeks of initial treatment, the most likely explanation is that the infection was not eradicated by a single course of treatment. Recurrence of vaginitis caused by sexually transmitted microbes is often attributable to a lack of partner treatment.

What can be done about these recurrences?

If recurrences of BV or yeast happen frequently–either because an infection is not improving with treatment, or an individual is particularly prone to repeat infection–longer courses of medication can be administered.

The general approach is to treat an active infection with one or more back-to-back doses of medicine to resolve symptoms, and then maintain symptom resolution with one-to-two doses of medication per week, usually for four-to-six months.

For instance, if symptoms of BV recur a couple of weeks after initial treatment with oral metronidazole, it’s reasonable to try the vaginal suppository version of metronidazole instead, or a different antibiotic altogether, such as clindamycin.

For frequent recurrences, the usual protocol is to treat symptoms with one course of oral medicine, then use metronidazole vaginal suppositories two nights per week for four-to-six months.

For frequent and recurrent yeast infections, a common treatment plan is oral fluconazole once every 72 hours for three doses, then once a week for six months.

Can boric acid help?

For frequent recurrences of BV and/or yeast, boric acid suppositories are often helpful, either in place of or in addition to antibiotic/antifungal pharmaceuticals. Boric acid is a weak acid that helps to promote proper pH balance in the vagina, which can be disrupted by BV and yeast.

For treatment of an infection, vaginal suppositories comprised of powdered boric acid are inserted nightly for two to three weeks. For maintenance therapy (i.e., prevention of frequent recurrence), boric acid suppositories can be used on an ongoing basis, usually one to two nights per week.

It’s important to note that boric acid is fatal if swallowed, so shouldn’t be confused with an oral pill, and should be kept out of reach of children and pets.

What about douches? Does cleansing hurt or help?

The key to maintaining vaginal health is protecting the bacterial balance of the vagina. It’s important to wash only with a mild, pH-balanced cleanser, and to avoid using soaps that are heavily fragranced or marketed as antibacterial.

It’s also critical to avoid douching. Although douches are meant to cleanse, the vagina is self-cleansing via natural lubricants and healthy bacterial flora. Introducing external ingredients– whether in a homemade douche or one that’s commercially available–can destroy the natural balance of the vagina and lead to bacterial or fungal infection. Similarly, vaginal sprays and powders are often advertised as methods of staying “clean” and “fresh,” but can have an unintended opposite effect.

Many women also find that condom use reduces recurrence of bacterial vaginosis, as well as being diligent about washing sex toys before and after using.

Can probiotics help?

For women who are vulnerable to recurrent BV or yeast, probiotics may have some benefit, either in dietary or supplement form. It is not recommended to insert probiotic supplements (or yogurt) vaginally.

What are some general lifestyle tips for yeast infection prevention?

For recurrent yeast infections, it’s most important to keep skin clean and dry. Changing into dry clothes after swimming/exercise, and wearing breathable, cotton underwear can help.

As with BV, avoid inserting anything into the vagina that might disrupt the pH and healthy bacterial balance.

Tea tree oil, yogurt, garlic, vitamin E, green tea, probiotics, and other foods and supplements have been touted as beneficial for vaginal health, but these interventions are not supported by research and risk disrupting the healthy bacterial balance of the vagina.

Related Topics

What are the different forms of vaginitis and how can I tell them apart?

Can men get a yeast infection or BV?

What causes recurrent vaginitis?

Can you treat vaginitis at home?

Is there a type of vaginitis that is an STD?

Useful Links

Vaginitis FAQs (American College of Obstetricians and Gynecologists)

Douching Fact Sheet (Office on Women's Health, HHS)

Bacterial Vaginosis (CDC)

Yeast Infection (CDC) Vaginal Discharge (AAFP)

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