The normal vaginal environment is a dynamic milieu with a constantly changing balance of Lactobacillus acidophilus and other endogenous flora, glycogen, estrogen, pH, and metabolic byproducts of flora and pathogens. L. acidophilus produces hydrogen peroxide that limits the growth of pathogenic bacteria. Disturbances in the vaginal environment can allow the proliferation of vaginitis-causing organisms. The term vulvovaginitis actually encompasses a variety of inflammatory lower genital tract disorders that may be secondary to infection, irritation, allergy, or systemic disease. Vulvovaginitis is the most common reason for gynecologic visits, with over 10 million office visits for vaginal discharge annually. It is usually characterized by vaginal discharge, vulvar itching and irritation, and sometimes vaginal odor. Up to 90% of vaginitis is secondary to bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. The actual prevalence and causes of vaginitis, however, are hard to gauge because of the frequency of self-diagnosis and self-treatment. In one survey of 105 women with chronic vaginal symptoms, 73% had self-treated with OTC products and 42% had used alternative therapies. On self-assessment, most women thought they had recurrent vulvovaginal candidiasis (RVVC), but upon diagnosis, only 28% were found positive for recurrent vulvovaginal candidiasis. Women with a prior diagnosis of vulvovaginal candidiasis (VVC), however, were able to accurately self-diagnose up to 82% of the time based solely on symptoms. This may, however, be an overestimate, as in another study (questionnaire) of 634 women, only 11% were able to accurately recognize the classic symptoms of vulvovaginal candidiasis. Another study of women who thought they had vulvovaginal candidiasis also found that self-assessment had limited accuracy, with only 33.7% of women with self-diagnosed yeast infection having microscopically confirmable cases.
Two-thirds of patients with vaginal discharge have an infectious cause. However, the presence of some amount of vaginal secretions can be normal, varying with age, the menstrual cycle, pregnancy, and the use of oral contraceptives.
Antibiotics, contraceptives, vaginal intercourse, receptive oral sex, stress, and hormones (e.g., HRT, endogenous hormonal dysregulation) can lead to overgrowth of pathogenic organisms. Chemical vulvovaginitis can be caused by colored and perfumed soaps, toilet paper, bubble baths, panty liners, tampons, sanitary pads, and douches. Latex condoms, topical antifungal agents, and preservatives and other agents in lubricants can cause allergic reactions leading to vulvovaginitis. In meno-pausal women, or those on antiestrogen therapies, decreased estrogen levels may lead to atrophic vaginitis, which if asymptomatic generally requires no treatment. Forty percent of postmenopausal women, however, are symptomatic; symptoms are readily treatable with topically applied lubricants, and the use of estrogen replacement therapies by topical or oral administration.
Although vaginal complaints may commonly be treated based on symptoms, studies have demonstrated a poor correlation between symptoms and diagnosis. Therefore, the most accurate diagnoses and thus the most appropriate treatments, can best be made with testing methods specific for individual organisms. Acute singular episodes of vaginal infections are referred to as uncomplicated, whereas recurrent vaginal infections are considered complicated. Complicated cases are often more severe, resistant to treatment, and may be associated with underlying systemic causes, for example, in VVC, uncontrolled diabetes, or immunosuppression.
The remainder of this section presents seperate discussions of the most common vaginal infections (Table Differential Symptoms and Signs of Common Vaginal Infections) followed by a discussion of the botanical treatment of vaginal infections. Table Common Causative Organisms, Agents, and Conditions Involved in the Etiology of Vulvovaginitis provides a general overview of common causative organisms, agents, and conditions involved in vulvovaginitis. It should be remembered that multiple causes of vaginitis may occur concurrently.
Differential Symptoms and Signs of Common Vaginal Infections
|Bacterial Vaginosis||Vulvovaginal Candidiasis||Trichomoniasis|
|Discharge color||Thin off-white discharge||Curdy whitish to yellowish-white discharge||Yellow green or colorless copious discharge|
|Discharge odor||Malodorous discharge with a characteristic “fishy” odor that may be increased after sexual intercourse||May have no odor, or odor may be reminiscent of yeasted bread||Malodorous|
|Physical findings||Discharge and odor may be apparent; discharge may be adherent to vaginal walls; tissue typically appears normal||Vulvovaginal redness, swelling, and fissures; discharge appears thick, whitish, and adherent to vaginal walls||Vulvovaginal redness, swelling, “strawberry” cervix. Frothy and purulent discharge is visible|
|Vaginal pH (normal <4.5)||High (>4.5)||Normal||High (>4.5)|
Common Causative Organisms, Agents, and Conditions Involved in the Etiology of Vulvovaginitis
|Organism / Agent / Condition||Examples|
|Bacterial vaginosis (BV)||Cardnerella vaginalis, Mycoplasma hominis, other anaerobic microorganisms|
|Vulvovaginal candidiasis (VVC)||Candida albicans, Candida tropicalis, Candida glabrata, other Candida species|
|Trichomoniasis Chemical vulvovaginitis||Trichomoniasis vaginalis Feminine hygiene products: tampons, sanitary pads, douches, latex condoms, spermicides, colored and perfumed soaps, toilet paper, bubble baths|
|Allergic vulvovaginitis||Latex condoms, topical antifungal agents, and preservatives and other agents in lubricants|
|Atrophic vulvovaginitis||Estrogen deficiency due to menopause, anti-estrogenic therapies, or hormonal dysregulation|
|General causes / factors that might lead to or increase susceptibility to vulvovaginal infection and WC||Antibiotics, oral contraceptives, use of diaphragms, spermicide, lUDs, frequent vaginal intercourse, receptive oral sex, stress, public hot tubs, hormones (e.g., imbalanced endogenous hormones, HRT), uncontrolled diabetes mellitus, immunosuppression (HIV / AIDS, steroids), pregnancy|
Sexual abuse must be ruled out in girls or young women with vulvovaginitis or recurrent vaginal infections.
Treatment Summary For Vulvovaginitis
- • Healthy vaginal flora and bowel flora must be promoted when there is chronic vulvovaginitis.
- • Avoid precipitating factors, for example, anything that might trigger chemical or allergic reaction, or mechanical irritation (e.g., tampons, sexual activity).
- • For infectious vulvovaginitis, consider antimicrobial herbs including Calendula, garlic, goldenseal, oregano, thyme, tea tree, Pau d’arco, marshmallow, lavender, and Oregon grape root.
- • For relief of irritation, itching, and inflammation use topical applications of calendula, marshmallow, com-frey, and lavender for their soothing, healing properties. Healing tissue can also reduce the spread of opportunistic infections such as HIV.
- • Use topical or oral preparations containing live, active acidophilus cultures to restore normal bowel and vaginal flora.
- • For chronic, recurrent vulvovaginitis, consider adding internal treatment for immune supporting and antimicrobial activity, including echinacea, goldenseal, Oregon grape root, and medicinal mushrooms. Also see Chapter 6 for a discussion on adaptogens and immune support.
- • The role of intestinal permeability or “leaky gut syndrome” and other bowel disorders should be evaluated in the treatment of chronic vulvovaginitis.
- • Limit or eliminate refined flour, refined sugar, dairy products, fruits, and fermented foods.
- • Supplement with 5 to 10 mg of zinc daily in intractable cases of yeast infection.
- • Use boric acid capsules as suppositories, especially for intractable bacterial vaginosis.
- • Loose fitting clothing made of natural fibers should be encouraged, especially during sleep.
- • Avoid douching.
- • Educate patient about vaginal hygiene and personal empowerment regarding healthy sexual behavior.
- • When appropriate and possible, treat sexual partners.