Vaginal infections

By Dr. Wong Heng Fok
Consultant Obstetrician & Gynaecologist, Urogynaecologist
MBBS (Singapore), MRCOG (London, UK)

Many women suffer in silence, unknowingly. In this article, Dr Wong H.F. shares with us his knowledge of Vulvovaginitis, also known as vaginal infection in women.

1. Thrush/Fungus

When doctors say "yeast," we usually refer to the fungus Candida albicans. It's commonly found on the skin and in the gastrointestinal tract anywhere from the mouth to the anus.

Candida can live in the vagina of up to one in five healthy women of childbearing age without causing any symptoms. Most of the time, a healthy vaginal environment and a normal immune system prevent the harmless yeast from overgrowing and causing vaginitis. A yeast infection occurs when there's an abundance of yeast. It completely overwhelms the vaginal defence system.

Yeast infections can cause a wide range of symptoms. In general, the more intense the itching and redness, the greater the presence of yeast organisms. In some women, secretions predominate, with profuse discharge that adheres to the vaginal wall in thick white patches or white plaques. This is also referred to as vaginal thrush. Odour is not a common complaint, though candida can cause a yeasty odour in some women.

This condition is usually diagnosed with a simple pelvic examination in which the vaginal discharge is swabbed and sent for culture.

Treatment usually consists of a combination of vaginal pessaries available on the market for one to seven days. We usually apply an anti-fungal/steroid cream to relieve local itchiness. If you have recurrent or persistent fungal infections, they can be difficult to treat, and you should see your GP or gynaecologist to confirm the diagnosis and rule out other conditions, such as bacterial vaginosis, which is just as common as fungal infections.

2. Bacterial vaginosis (BV)

This condition is as common as yeast/thrush or fungal infection and manifests as vaginal discharge (which may be yellow green as opposed to white discharge in yeast infection). The difference between fungal infections and BV is that BV discharge is foul-smelling with a fishy odour and is the leading cause of unpleasant odours. It may also cause pain and irritation around the vulva.

We can usually confirm the diagnosis by obtaining a vaginal swab and sending it to the laboratory. In the meantime, we usually order vaginal pessaries or even oral medication for 7 to 10 days. The most common are Gardnerella and Trichomonas infections.

BV, like yeast infections, is not a sexually transmitted infection, but rather a bacterial imbalance in the vaginal environment. You should see a gynaecologist or a GP for treatment.

3. Sexually transmitted disease (STD)

There are numerous STDs to discuss, but we will only cover the most common ones here.

i) Herpes infection

Herpes simplex virus (HSV) infections are very common all over the world. HSV-1 is the most common cause of herpes infections on the lips and mouth, including cold sores and fever blisters. It is spread by kissing. HSV-1 can also cause genital herpes, but HSV-2 is the most common cause. HSV-2 is contracted through sexual contact. You could be infected with HSV-1 or HSV-2 but have no symptoms. Symptoms are often brought on by exposure to the sun, fever, menstruation, emotional stress, illness, or a weak immune system.

Herpes has no cure and is likely to reoccur. However, some people may have one outbreak and never have another.

Genital herpes causes multiple painful blisters and ulcers around the vulva and perineum (area immediately next to the vagina) and, in severe cases, may cause difficulty passing urine due to pain

Most of the time, your doctor will be able to tell if you have herpes just by looking at you. However, if your doctor is unsure, he or she may take a sample from the blisters to test for the virus.

Antiviral drugs might help shorten the length of a herpes outbreak and stop it from happening again. We give oral tablets and a topical antiviral cream for a week. Some patients require admission due to the severity of their ulcers.

ii) Chlamydiae

Chlamydiae is a common sexually transmitted disease (STD) caused by the bacterium Chlamydia trachomatis that can damage a woman's reproductive organs. Even if the symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, such as infertility, can occur "silently" before a woman is aware of a problem. Chlamydia can also cause discharge from the penis of an infected man.

Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United States, particularly among young girls.

Anyone who engages in sexual activity can become infected with chlamydia. The greater the number of sex partners, the greater the risk of infection. Teenage girls and young women are especially vulnerable to infection if sexually active because their cervix (opening to the uterus) is not fully mature and is likely more susceptible to infection.

Chlamydia is known as a "silent" disease because the majority of infected people show no symptoms. If symptoms do appear, they usually do so 1 to 3 weeks after exposure.

In women, the bacteria first infect the cervix and urethra (urine canal). Women experiencing symptoms may experience abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from the cervix to the fallopian tubes (tubes that carry fertilised eggs from the ovaries to the uterus), some women have no symptoms, while others have lower abdominal pain and fever.

If a woman doesn't get treatment for an infection, it can spread to the uterus or fallopian tubes and cause pelvic inflammatory disease. This occurs in about 10 to 15 percent of women with untreated chlamydiae and may lead to fertility issues later in life.

Chlamydia can be easily treated and cured with antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments.

When an STD is discovered, contact tracing of the male partner is needed, and all sex partners must be evaluated, tested, and treated.

iii) Gonorrhoea

Gonorrhoea is a sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, a bacterium that thrives in the warm, moist environment of the reproductive tract.

Anyone who engages in sexual activity is at risk of contracting gonorrhea.

The symptoms of gonorrhea in women are frequently mild, and the majority of infected women have no symptoms at all. Even when a woman experiences symptoms, they can be so non-specific and can be mistaken as a bladder or vaginal infection. Some of the first symptoms and signs in women are pain or burning when they urinate, more discharge from the vaginal canal, or bleeding between periods.

Gonorrhoea can lead to pelvic inflammatory disease (PID), which can cause internal abscesses (pus-filled “pockets” that are hard to treat) and long-term, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy.

Again, a vaginal swab can easily diagnose the condition, and antibiotics can treat it. See your gynaecologist for treatment.

iv) Genital warts

Genital warts are usually asymptomatic, but depending on their size and anatomic location, they can be painful, itchy, or cause cauliflower-like growths. They usually occur outside the vaginal and anus. They can appear in the vagina and around the cervix at times.

The diagnosis of genital warts is usually clinical, based on visual examination.

External warts (outside of the vagina) can be treated with a topical cream applied three times per week for six to 12 weeks. Internal vaginal warts or warts that do not respond to topical cream may necessitate laser vaporisation, which is a day surgery procedure performed under general anaesthesia.