VAGINAL DISCHARGE

NORMAL VAGINAL DISCHARGE

Discharge is common to all women and helps vaginas
stay healthy by regularly flushing them out and
maintaining their pH.
A normal vaginal discharge consists of about a teaspoon
(4 milliliters) a day that is white or transparent, thick to
thin, and odorl
This is formed by the normal bacteria and fluids the
vaginal cells put off. The discharge can be more
noticeable at different times of the month depending on
ovulation, menstrual flow, sexual activity and birth
control.
ABNORMAL VAGINAL DISCHARGE
When is vaginal discharge a sign of
an infection?
Your vaginal discharge might be a sign
of an infection if it:
1-Causes itching
2-Causes swelling
3-Has a bad odor
4-Is green, yellow, or gray in color
5-Looks foamy or like cottage cheese

It is not uncommon for the normal discharge to be dark,

brown or discolored a day or two following the menstrual
period.
The following situations can increase the amount of normal
vaginal discharge:
1-Emotional stress
2-Ovulation (the production and release of an egg from your
ovary in the middle of your menstrual cycle)
3-Pregnancy
4-Sexual excitement

Here are some key ways to determine if your vaginal discharge is normal
or if you have cause for concern:
Normal
Cause for concern
Colour
Clear or whitish discharge (may be Yellow or greenish discharge, or
yellowish when dried)
discharge that suddenly
changes color
Scent
Mild scent or none at all
A strong, foul, sometimes
"fishy" odor, or a sudden
change in odor
Texture
Can vary from "paste" like and
Clumpy or lumpy discharge,
somewhat sticky to clear and
with "cottage cheese" like
stretchy, depending on where you
texture
are in your cycle and whether you
are aroused
Volume
Can vary from very little to quite a Sudden changes in volume,

lot (particularly when ovulating or

aroused)

ABNORMAL VAGINAL DISCHARGE

May be due to:

particularly if other symptoms

are present

1. Atrophic vaginitis (seen in

women who have gone through
menopause and have low estrogen
levels)
2. Bacterial vaginosis (BV) -Bacteria that normally live in the
vagina overgrow, causing a grey
discharge and fishy odor that
worsen after sexual intercourse. BV
is usually not sexually transmitted.
3. Cervical or vaginal cancer
(rarely a cause of excess
discharge)
4. Chlamydia
5. Desquamative vaginitis
and lichen planus
6. Forgotten tampon or foreign
body
7. Gonorrhea
8. Other infections and sexually
transmitted diseases
9. Trichomoniasis
10.
Vaginal yeast infection
11.
Allergic reactions,Cervical
polyp,Cervicitis, Genital Warts
(HPV), Pelvic inflammatory
disease
CANDIDAL VAGINITIS
common vaginal infection in

Risk factors

Clinical Presentation

the United States.

Etiology
The etiologic agent is a
yeast (fungi) organism,
usually Candida albicans.
The organism is a
common inhabitant of the
bowel and perianal region
Thirty percent of women
may have vaginal
colonization and have no
symptoms of infection.

Contraceptive practices
(e.g., birth control pills
and vaginal spermicides,
which influence vaginal
pH)
Use of systemic
steroids, which influence
the immune system
Use of antibiotics, which
alters the microbiology of
the vagina; 25% to 70% of
women report yeast
infections after antibiotic
use. Any antibiotic,
particularly a broadspectrum agent, may play
a causative role.
Tight clothing, panty
hose, and bathing suits
(yeast thrives in a dark,
warm, moist environment)
Undiagnosed or
uncontrolled diabetes
mellitus

Diagnosis
Diagnosis is made by history,
physical examination, and
microscopic examination of the
vaginal discharge in saline and 10%
KOH.

Another reason for a

refractory monilial
infection may be
compromised immune
status; with recurrent
monilial vaginitis, an HIV
test is indicated, along
with a fasting serum
glucose level.
There has been a recent
increase in the number of
infections caused by nonalbicans species. Up to
20% of infections maybe
caused by organisms such
as Candida tropicalis and
Torulopsis glabrata. These
organisms may be
resistant to standard
treatment regimens

Infection with C. tropicalis and

T glabrata may not be
associated with the classic
discharge; discharge may be
white-gray and thin.

Patients with monilial

vaginitis characteristically
complain of a thick,
white discharge and
extreme vulvar
pruritus. The vulva may
be red and swollen,
fissures may occur
Symptoms may recur and
be most prominent just
before menses or in
association with
intercourse
Yeast infections may occur
more frequently during
pregnancy
Patients with infections
caused by C. tropicalis
and T glabrata may have
an atypical presentation.
Irritation may be
paramount, with little
discharge or pruritus.

Wet mount microscopic examination

reveals hyphae or pseudohyphae with
budding yeast in 50% to 70% of women
with yeast infections.
Cultures are not necessary to make the

On examination, excoriations of the

vulva may be noticeable; the vulva
and vagina may be erythematous,
with patches of adherent cottage
cheese-like discharge. Candidal
infections of the vulva are
characterized by classic satellite
lesions.

CANDIDAL VAGINITIS
Treatment
Many agents are available for the
treatment of vulvovaginal
candidiasis. These include topical
agents, which may be available over
the counter (OTC) or by prescription,
and oral agents, which are available
by prescription only.
1. Antifungal intravaginal agents
are administered as suppositories or
creams. These drugs are available in
three regimens: a single dose, 3-day
course, or 7-day course. Agents
include butoconazole, clotrimazole,
miconazole, tioconazole, and
terconazole. OTC regimens should
be used only by women who have
been diagnosed with a yeast

#Vaginal pH may be normal or

slightly more basic than normal
(4.0 to 4.7).

2. Oral Agents:
Ketoconazole,
Fluconazole
Fluconazole is available as a
single-dose (150 mg)
treatment for uncomplicated
vaginal candidiasis.
-Ketoconazole is used
effectively for the treatment of
chronic and recurrent
candidiasis; a 5% incidence of
hepatotoxicity limits more
widespread use. The dosing
schedule is 200 mg twice a
day for 5 days, then 100 to
200 mg daily for 6 months
3. Boric acid capsules

diagnosis except in some cases of

recurrent infections.

Chronic yeast infection

(5% of women). In most cases, no exacerbating
factor can be found; however, the following
possibilities should be considered
1-Failure to complete a full course of
therapy.
2-HIV infection. Recalcitrant candidiasis may be
a presenting symptom in women with HIV
infection. HIV testing should be considered and
offered to the patient.
3-Chronic antibiotic therapy.
4-Infection with a resistant organism such as
C. tropicalis or T glabrata.
5-Sexual transmission from the male partner.
6-Allergic reaction to partner's semen or a
vaginal spermicide.
7-Diabetes. Patients should have a fasting serum
glucose level if they have recurrent infections.

infection in the past and are

experiencing identical symptoms.

intravaginally, 600 mg for

14 days, may be effective.

TRICHOMONAS VAGINALIS
Trichomonas vaginalis vaginitis (trichomoniasis) is the third most common vaginitis, accounting for 25% of cases.
Etiology
trichomonad can be recovered from 70% to 80% of the
This parasite is usually a marker of high-risk sexual
male partners of the infected patient; therefore,
behavior, and co-infection with other sexually
Trichomonas vaginitis is an STD.
transmitted pathogens is common, especially Neisseria
#This infection is the most prevalent nonviral STD in the
gonorrhoeae. Trichomonas vaginalis has predilection for
United States (Van der Pol, 2005, 2007). Unlike other STDs,
squamous epithelium, and lesions may increase
its incidence appears to increase with age in some studies.
accessibility to other sexually transmitted species.
Trichomoniasis is more commonly diagnosed in women
Vertical transmission during birth is possible and may
because most men are asymptomatic. However, up to 70
persist for a year.
percent of male partners of women with vaginal
trichomoniasis will have trichomonads in their urinary tract.

TRICHOMONAS VAGINALIS
Clinical presentation
Trichomonas vaginitis is a multifocal infection involving
the vaginal epithelium, Skene glands, Bartholin glands,
and urethra.
No symptoms may be noted in up to one-half of women
with trichomoniasis. However, in those with complaints,
vaginal discharge is typically described as foul, thin, and
yellow or green. Additionally, dysuria, dyspareunia, vulvar
pruritus, and pain may be noted. At times,
symptomatology and physical findings are identical to

Diagnosis
Incubation with T vaginalis requires 3 days to 4 weeks, and
the vagina, urethra, endocervix, and bladder can be
infected, such colonization may persist for months or
years in some women.
With trichomoniasis, the vulva may be erythematous,
edematous, and excoriated. The vagina contains the
above-described discharge, and subepithelial hemorrhages
or "strawberry spots" may be seen on the vagina and
cervix. Trichomoniasis is typically diagnosed by

those of acute pelvic inflammatory disease.

Laboratory tests
1-The vaginal pH is usually between 5.0 and 7.0.
2-Saline wet mount of the vaginal discharge reveals
numerous leukocytes and the highly motile, flagellated
trichomonads (as many as 75% of cases).
3-Cultures are not usually necessary to make the diagnosis.
They should be obtained when the diagnosis is suspected but
cannot be confirmed by wet mount examination.
4-Pap smears may be positive in as many as 65% of cases.
Positive Pap smears should be confirmed by wet mount
examination because of the high false-positive rate.

TRICHOMONAS VAGINALIS
Treatment

microscopic identification of parasites in a saline

preparation of the discharge.
Trichomonads are anteriorly flagellated, and therefore
mobile, anaerobic protozoa. They are oval and slightly
larger than a white blood cell (WBC). Trichomonads
become less motile with cooling, and slides should be read
within 20 minutes. Inspection of a saline preparation is
highly specific, yet sensitivity is not as high as hoped (60
to 70 percent). In addition to microscopy, vaginal pH is
often elevated
The most sensitive diagnostic technique is culture, which
is impractical because special media (Diamond media) is
required and few laboratories are equipped. Moreover,
nucleic acid amplification tests (NAAT) for trichomonal
DNA are sensitive and specific, but not widely available.
Alternatively, the OSOM Trichomonas Rapid Test
(Genzyme, Cambridge, MA) is an immunochromatographic
assay, which has 88 percent sensitivity and 99 percent
specificity. It is available for office use, and results are
available in 10 minutes (Huppert, 2005). Trichomonads
may also be noted on Pap smear screening and sensitivity
approximates 60 percent.
Women with trichomonal infection should be tested for
other sexually transmitted infections. Additionally, sexual
contact(s) should be evaluated or referred for evaluation

Because Trichomonas is sexually transmitted, both partners require therapy; 25% of women will be reinfected if their
partner does not receive treatment.
A-Vaginal therapy alone is ineffective because of the multiple sites of infection, and systemic agents are necessary.
B-If both partners are treated simultaneously, cure rates of 90% are achieved with treatment with metronidazole. Patients
should be warned that a disulfiram-like reaction may occur and that they should abstain from alcohol use during treatment.
1-The preferred regimen is 2g in one dose because of ease of compliance. As many as 10% of patients may experience
vomiting.
2-An alternative regimen is 500 mg twice daily for 7 days.
C-Resistant cases may require treatment with intravenous metronidazole. Because resistance is rare, other causes, such as
noncompliance of the patient or partner, should be considered.
D-Metronidazole is contraindicated for use during the first trimester of pregnancy. After this time, it can be used to treat
Trichomonas infections.
E-Infected patients should be screened for other STDs.
BACTERIAL VAGINOSIS
Bacterial vaginosis is the
Etiology
Risk factors
Bacterial vaginosis is a
This condition is not considered by the Centers for
most common vaginal
infection in the United States
polymicrobial clinical syndrome
Disease Control and Prevention (CDC) consensus
today. In the past, bacterial
caused by an overgrowth of a
group to be a sexually transmitted disease (STD),
vaginitis was known as
variety of bacterial species,
and it is seen in women without previous sexual
nonspecific vaginitis and
particularly anaerobes, often
experience. Many risk factors, however, are
Gardnerella vaginitis.
found normally in the vagina.
associated with sexual activity, and an increased
Organisms most often involved
risk of acquiring STDs has been reported in
include Bacteroides,
affected women
Peptostreptococcus, Gardnerella
1-Oral sex
vaginalis, and Mycoplasma
2-Douching
hominis.
3-Black race
The anaerobic bacteria produce
4-Cigarette smoking
enzymes that break down
5-Sex during menses
peptides to amino acids and
6-Intrauterine device
amines, resulting in compounds
7-Early age of sexual intercourse

associated with the discharge and

odor characteristic of this
infection.

BACTERIAL VAGINOSIS
Clinical presentation
Fifty percent of women
with bacterial vaginosis
are asymptomatic.
In symptomatic patients,
the most common
presentation is a
malodorous, gray
discharge.
Treatment

8-New or multiple sexual partners

9-Sexual activity with other women

Diagnosis
Three of the following four criteria must be present:
A-The vaginal pH is generally between 5.0 and 5.5.
B-Wet mount preparations with saline reveal a CLUE CELL background with minimal or no
leukocytes, an abundance of bacteria, and the characteristic clue cells. The clue cells are
squamous cells in which coccobacillary bacteria have obscured the sharp borders and
cytoplasm.
C-Application of 10% KOH to the wet mount specimen produces a fishy odor, indicating a
positive WHIFF test.
D-A gray, homogenous, malodorous discharge is present

Therapy is based on the use of agents with anaerobic activity and involves both topical and systemic agents. The
combination appears to be 90% effective
A-Vaginal preparations:
1-Intravaginal 2% clindamycin cream is used at bedtime for 7 days.
2-Intravaginal metronidazole is applied once a day for 5 days.
B-Oral regimens:
1-Metronidazole may be administered two ways: 500 mg twice daily for 7 days or a single, 2-g dose.
2-Clindamycin, 300 mg twice daily for 7 days (may be associated with diarrhea, especially Clostridium difficile)
C-Sexual partners should be treated in cases of repeated episodes of bacterial vaginosis. Routine treatment of
partners has not been shown to improve cure rates or lower reinfection rates.
D-Treatment during pregnancy is critical; data suggest an association of adverse maternal and fetal outcomes
with bacterial vaginosis.
1-Clindamycin may be used throughout pregnancy.
2-Metronidazole may be used after the first trimester.
E-Patients with recurrences should be screened for STDs

PREVENTION

To help prevent and treat

vaginal discharge:
1-Keep your genital area
clean and dry.
2-Do not douche. While
many women feel cleaner if
they douche after
menstruation or intercourse,
it may actually worsen
vaginal discharge because it
removes healthy bacteria
lining the vagina that are
there to protect you from
infection. It can also lead to
infection in the uterus and
fallopian tubes, and is never
recommended.
3-Use an over-the-counter
yeast infection treatment
cream or vaginal
suppository, if you know
that you have a yeast
infection.
4-Eat yogurt with live
cultures or take
Lactobacillus acidophilus
tablets when you are on
antibiotics to avoid a yeast
infection.

5-Use condoms to avoid

catching or spreading
sexually transmitted
diseases.
6-Avoid using feminine
hygiene sprays, fragrances,
or powders in the genital
area.
7-Avoid wearing extremely
tight-fitting pants or
shorts, which may cause
irritation.
8-Wear cotton underwear
or cotton-crotch
pantyhose. Avoid underwear
made of silk or nylon,
because these materials are
not very absorbent and
restrict air flow. This can
increase sweating in the
genital area, which can cause
irritation.
9-Use pads and not
tampons.
10-Keep your blood sugar
levels under good control
if you have diabetes

If the discharge is caused by

a sexually transmitted
disease, your sexual
partner (or partners) must
be treated as well, even if
they have no symptoms.
Failure of partners to accept
treatment can cause the
infection to keep coming back
and may lead to pelvic
inflammatory disease or
infertility.
Call your doctor rightaway if:
#Your discharge is associated
with fever or pain in your
pelvis or abdomen.
#You have been exposed to a
sexual partner with
gonorrhea, chlamydia, or
other sexually transmitted
disease.
#You have increased thirst or
appetite, unexplained weight
loss, increased urinary
frequency, or fatigue - these
may be signs of diabetes

Also call if:

#A child who has not reached
puberty has vaginal
discharge.
#You think that your
discharge may be related to a
medication.
#You are concerned that you
may have a sexually
transmitted disease or you
are unsure of possible
exposure.
#Your symptoms worsen or
last longer than 1 week
despite home care measures.
#You have blisters or other
lesions on your vagina or
vulva (exterior genitalia).
#You have burning with
urination or other urinary
symptoms -- you may have a
urinary tract infection.