• Increased volume of vaginal secretions
• Abnormal color, consistency, or odor of vaginal secretions
• Vulvovaginal itching, burning, or irritation
• Painful urination or intercourse
Vaginitis is an infection of the vaginal tract. It is one of the most common reasons for women to seek medical attention. In addition to causing physical discomfort and embarrassment, vaginitis is medically important for several reasons: (1) it may be a symptom of a more serious underlying problem, such as chronic inflammation of the cervix (cervicitis) or a sexually transmitted disease; (2) the infection may travel into the uterus and lead to pelvic inflammatory disease, a serious situation that can result in infertility due to scarring of the fallopian tubes; and (3) chronic vaginal infections are often the underlying cause of recurrent urinary tract infections because they serve as a reservoir of the infectious bacteria.
Causes
Vaginitis may be sexually transmitted or may arise from a disturbance to the delicate ecology of the healthy vagina. In many instances, vaginal infections involve an overgrowth of common organisms normally found in the vagina of many healthy women. In normal situations these microbes do not cause any problems, but when there is a disturbance in the vaginal environment a normally present microbe can overgrow and produce an infection.
Factors influencing the vaginal environment include pH, tissue sugar (glycogen) content, blood sugar (glucose) level, presence of “friendly” organisms (particularly Lactobacillus acidophilus), natural flushing action of vaginal secretions, presence of blood (menstruation), spermicides and lubricants, and presence of antibodies and other compounds in the vaginal secretions. These factors are, in turn, affected by such things as low immune function as a result of nutritional deficiencies, medications (e.g., steroids, birth control pills), pregnancy, serious illness, diabetes, and the wearing of panty hose (which tend to prevent drying of the area). In fact, vaginal yeast infections are three times more prevalent in women wearing panty hose than those wearing cotton underwear.1
Risk factors for sexually transmitted infections include increased numbers of sexual partners, unusual sexual practices, and the type of birth control used (barrier methods reduce risk of infection, while birth control pills increase risk of infection).
Approximately 90% of cases of vulvovaginitis will be associated with one of three organisms, Trichomonas vaginalis, Candida albicans, or Gardnerella vaginalis. The relative frequency of each form varies with the population studied, as well as with sexual activity levels. Less frequent causes of vaginitis include Neisseria gonorrhea, herpesvirus, and Chlamydia trachomatis. Each is described more fully below.
The preceding table summarizes the diagnostic differentiation of the most common causes of infectious vaginitis.
The relative frequency and the total incidence of vaginal yeast infections (candidal vaginitis) have increased dramatically in the past 40 years. Several factors have contributed to this increased incidence, chief among them being the increased use of antibiotics. The problem with vaginal yeast infections as a result of antibiotic use is well known by virtually every woman.
Most cases of recurrent candidal vaginitis are due either to transmission of candida from the gastrointestinal tract or to failure to recognize and treat the presence of one or more predisposing factors.2 In extremely persistent cases, sexual partners may be a source of reinfection. Allergies have also been reported to cause recurrent candidiasis, which resolves when the allergies are treated.3
Predisposing Factors in Candidal Vaginitis
Allergies
Antibiotics
Diabetes
Elevated vaginal pH
Gastrointestinal candidiasis
Oral contraceptives
Panty hose
Pregnancy
Steroids
The primary symptom of a vaginal yeast infection is vulvar itching, which can be quite severe. Candida vaginitis is often associated with the presence of a thick, curdy, or “cottage cheese” discharge, which may reveal pinpoint bleeding when removed. The presence of such a discharge is strong evidence of a yeast infection, but its absence does not rule out candida.
This category is defined as vaginitis not due to trichomonas, gonorrhea, or candida. Whereas itching is the predominant symptom of candidal vaginitis, the presence of a discharge and odor are the keynotes of nonspecific vaginitis (NSV) or bacterial vaginosis (BV). Both terms are used to describe a shift in vaginal flora from a predominance of lactobacilli to a predominance of a type of bacteria that degrade the mucins forming a natural barrier on the vaginal lining. This destruction of the mucin layer causes a vaginal discharge characteristic of NSV/BV. The odor is variously described as fishy, foul, or rotten, and reflects the production of the breakdown of proteins by bacteria. The discharge is nonirritating, gray, and usually of even consistency, though it may occasionally be frothy or even thick and pasty.
One of the most common causes of NSV/BV is routine douching. This practice is associated with a loss of vaginal lactobacilli. The organism most frequently cited as responsible for NSV/BV is Gardnerella vaginalis (formerly called Haemophilus vaginalis). However, although this bacterium is found in 95% of women with NSV/BV, it is also found in 40% of women who do not have vaginitis. It is very likely that Gardnerella vaginalis prospers in the conditions of NSV/BV but that the responsible organism may be another type of bacteria or simply the loss of proper balance in the vagina.
Trichomonas vaginalis is a single-celled organism that is transmitted by sexual intercourse. Trichomonas does not invade tissues and rarely causes serious complications. The most frequent symptom is vaginal discharge with itching and burning. The discharge is frequently smelly, greenish yellow, and frothy. This organism grows optimally at a pH of 5.5 to 5.8. Thus, a vaginal pH outside this range in a woman with vaginitis is suggestive of an agent other than trichomonas. Looking at vaginal fluid under a microscope will confirm the diagnosis in 80 to 90% of cases.
Neisseria gonorrhea is an uncommon cause of vaginitis, responsible for less than 4% of cases. Gonococcal vaginitis is more common in young girls because the vaginal epithelium is thinner before puberty. During the reproductive years, severe infection of the cervix is the primary symptom (painful, bloody, pus-filled discharge). Gonorrhea, either alone or in combination with other organisms, is cultured in 40 to 60% of cases of pelvic inflammatory disease, a major cause of infertility. Because of the potential for serious consequences, sexually active women experiencing any symptoms suggestive of gonorrhea must consult a physician immediately.
Herpes simplex (herpesvirus infection) is the most common cause of genital ulcers in the United States. For a more thorough discussion see the chapter “Herpes.”
Chlamydia trachomatis is a parasite that lives within human cells. It rarely causes vaginitis on its own but is frequently found in association with other common causes such as Candida albicans. Chlamydia is another sexually transmitted disease that is now recognized as a major health problem in the United States. Chlamydia infects 5 to 10% of sexually active women and is usually without symptoms until the development of complications, such as infections of the cervix, fallopian tubes, or urethra. Chlamydia is the organism most frequently recovered in cultures of women with pelvic inflammatory disease, a severe infection of the female genital tract. Chlamydia infections are the major cause of infertility due to scarring of the fallopian tubes.
Chlamydial infection during pregnancy increases the risk of prematurity and infant death. If a healthy baby is born to an infected woman, there is a 50% chance it will develop chlamydial infection of the eyes and a 10% chance of pneumonia. Because of the considerable risks of untreated chlamydia, we again recommend consulting a physician immediately if you are suffering from any suspicious symptoms.
Therapeutic Considerations
Although vaginitis is usually due to Candida albicans and is almost always self-treated with over-the-counter preparations, there is the possibility of a more serious cause of vaginitis, and so we strongly recommend consulting a physician for a definitive diagnosis. The natural treatments given below are recommended only after consultation with a health care provider. The focus is on the treatment of candida vaginitis, but the same principles also apply to trichomonas, NSV, and BV. For chlamydial and gonorrheal vaginitis we recommend conventional antibiotic therapy given the serious risk of tubal scarring and other complications.
WARNING: Be sure to fully follow the antibiotic dosage and duration as prescribed for gonorrhea and chlamydial infections. Incomplete eradication of the bacteria in the deeper tissues can result in chronic, unrecognized infection that can lead to infertility.
The goals of therapy are to identify and eliminate or reduce contributing factors, to improve immune function and defense mechanisms, and to reestablish proper bacterial flora.
The recommendations in the chapter “Candidiasis, Chronic,” are appropriate here, especially in dealing with candida vaginitis. Do not eat refined carbohydrates and simple sugars. Do not eat foods with a high content of yeast or mold, including alcoholic beverages, cheeses, dried fruits, melons, and peanuts. Avoid all known or suspected food allergies.
Lactobacillus acidophilus
The normal microflora of the vagina is dominated by lactobacilli capable of inhibiting the adhesion and growth of infectious organisms. Lactobacilli produce this effect through at least three mechanisms: (1) they help to produce lactic acid and other acids to provide a normal vaginal acidic environment of 3.5 to 4.5, which inhibits the growth of many disease-causing organisms; (2) lactobacilli produce hydrogen peroxide, which inhibits microbial growth; and (3) lactobacilli are competitive with other microorganisms for adherence to the vaginal lining.4–6
Due to the importance of lactobacilli, one of the primary goals in successfully treating and preventing recurrent vaginal infections is reestablishing the normal vaginal flora. In particular, Lactobacillus acidophilus is an integral component of the normal vaginal flora and helps to prevent the overgrowth of Candida albicans and less desirable bacterial species.
Reestablishment of normal vaginal lactobacilli can be accomplished by douching twice a day with an acidophilus-containing solution. The solution can be prepared by using a high-quality acidophilus supplement or an active-culture yogurt (careful reading of labels is important, since most commercially available yogurts do not use live lactobacilli). Dissolve enough of either choice in 10 ml water to provide 10 billion organisms. Use a syringe to douche the material into the vagina. Since lactobacilli are normal inhabitants of the vaginal flora, the douche can be retained in the vagina as long as desired. We suggest also taking lactobacilli orally, as women with vaginal yeast overgrowth will often have an overgrowth in the gut as well. Several clinical studies have confirmed that the use of lactobacillus in the vagina as well as oral supplementation is effective in eliminating candidal vaginitis and improving the vaginal flora.7–11
Vitamin C
Vaginal vitamin C therapy has been used to treat BV. A randomized, double-blind, placebo-controlled study used one 250-mg tablet of vitamin C inserted vaginally once a day for six days. Fifty subjects were given the active treatment and 50 were given a placebo. Significantly more patients still had BV in the placebo group (35.7%) compared with the vitamin C group (14%). Anaerobic bacteria disappeared in 77% of the vitamin C group vs. 54% of the placebo group, and lactobacilli reappeared in 79.1% of vitamin C group vs. 53.3% in the placebo group.12
Local Antiseptics
There are a number of natural antiseptic compounds that can be used during the infectious stage to get rid of the offending organisms. The discussion below will focus on iodine, boric acid, and tea tree oil, as these appear to be the most effective. In fact, their effectiveness has been shown to be as good as or better than that of standard antibiotic therapy for the common causes of vaginitis (Trichomonas vaginalis, Candida albicans, and Gardnerella vaginalis). Be sure to always follow these antimicrobial douches with lactobacilli douches.
Iodine. Iodine used topically as a douche is effective against a wide range of infectious agents linked to vaginal infections, including those due to trichomonas, candida, chlamydia, and nonspecific vaginitis. This is the strongest of the douches, so we recommend it be used only if the gentler approaches are inadequate. Povidone-iodine solution (Betadine) has all the advantages of iodine without the disadvantages of stinging and staining. Betadine is available at any pharmacy. A douching solution diluted to 1 tsp povidone-iodine solution in 2 cups water used twice per day for 14 days is effective against most organisms.13–19 A study published in 1962 found povidone-iodine to be effective in treating 100% of cases of candidal vaginitis, 80% of cases of trichomonas, and 93% of cases of combination infections.18 However, excessive use must be avoided, since some iodine will be absorbed into the system and can cause suppression of thyroid function. In addition, recognize that iodine is indiscriminate in the bacteria it kills, so following up with a lactobacilli douche is critical.
Boric Acid. Capsules of boric acid inserted into the vagina have been used to treat candidiasis with success rates equal to or better than those of nystatin and creams containing miconazole, clotrimazole, or butoconazole.20–23 Boric acid treatment offers an inexpensive, easily accessible therapy for vaginal yeast infections. In a study of 92 women with chronic vaginal yeast infections, boric acid treatment was shown to be significantly more effective.23 The dosage was 600 mg boric acid in a vaginal suppository twice per day for two weeks. As well as being more effective in relieving symptoms, boric acid also demonstrated a more significant improvement with microscopic examination of a vaginal swab. In fact, no patient receiving antifungal drugs had a normal microscopic exam. All exams in these patients demonstrated continued presence of yeast, damaged cells lining the vagina, or some other abnormality.
Outcome of Therapy with Conventional Antifungal Agents and Boric Acid |
||
AGENT |
RESOLUTION OF SYMPTOMS(% OF PATIENTS) |
ABNORMAL MICROSCOPIC FINDINGS(% OF PATIENTS) |
Antifungals |
52% |
100% |
Boric acid |
98% |
2% |
In chronic cases of vaginal yeast infections standard antifungal agents are often ineffective. In these cases, it is definitely recommended that boric acid (600 mg) be used twice a day for four months. After this time further use may not be necessary except during menstruation.
Side effects with boric acid are quite rare. The most common side effect is burning of the labia due to boric acid leaking out of the vagina. If this occurs, reduce the amount of boric acid or discontinue use.
Tea Tree Oil. Tea tree (Melaleuca alternifolia) oil diluted to 1% in water exerts a strong antibacterial and antifungal action. It was shown in one study to be effective in treatment of trichomoniasis, candidiasis, and cervicitis. Treatment consists of a daily douche combined with saturated tampons used weekly. No adverse reactions were reported, and patients commented favorably on its soothing effect.24
QUICK REVIEW
• Consult a physician for immediate and accurate diagnosis of vaginal infections.
• Infectious vaginitis may be sexually transmitted or may arise from a disturbance to the ecology of the healthy vagina.
• Approximately 90% of vulvovaginitis will be associated with one of three organisms: Trichomonas vaginalis, Candida albicans, or Gardnerella vaginalis.
• The goals of therapy are to identify and eliminate or reduce contributing factors, improve immune function and defense mechanisms, and reestablish proper bacterial flora with Lactobacillus acidophilus.
• Iodine, boric acid, and tea tree oil can be used as vaginal antiseptics.
TREATMENT SUMMARY
Since approximately 90% of all vaginitis is due to candida, trichomonas, or Gardnerella infections, the following recommendations are primarily directed toward treatment of these organisms. Immune support (through proper diet, nutritional supplementation, and botanical medicines) is an important aspect of the therapy. For recurrent infections, please follow the recommendations in the chapter “Immune System Support.”
• Consult a physician for accurate diagnosis.
• Treatment failures may be due to incorrect diagnosis, reinfection, failure to treat predisposing factors, or resistance to the treatment used.
• In all cases of vaginitis, it is important to use live lactobacillus preparations to reestablish in the vagina a healthy colony of these desirable organisms.
• Sexual activity should be avoided during treatment to avoid reinfection and to reduce trauma to inflamed tissues. If this is not possible, at least ensure that condoms are used.
• In recurrent cases consider treating sexual partners.
• Wear cotton underwear.
The recommendations in the chapter “Candidiasis, Chronic,” are appropriate here, especially in dealing with candida vaginitis. Do not eat refined carbohydrates and simple sugars. Do not eat foods with a high content of yeast or mold, including alcoholic beverages, cheeses, dried fruits, melons, and peanuts. Avoid all known or suspected food allergies.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Or some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• Probiotic (Lactobacillus species and Bifidobacterium species): a minimum of 5 billion to 20 billion colony-forming units per day
• One or more of the following agents (do not try to include all at once, as the variety provides alternatives for use in resistant cases):
Betadine (povidone-iodine solution): 1:100 dilution used as a douche twice per day for 14 days
Boric acid capsules: 600-mg capsule placed in vagina twice per day for 14 days (Caution: Repeated use of povidone-iodine solution or boric acid may cause irritation, and use for more than seven days may result in problems from systemic absorption.)
Lactobacillus species: Dissolve enough in 10 ml water to provide 10 billion organisms and use as a douche once per day for 14 days.
